Formulary 2016

( M E D I C A R E

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M E D I C A I D

P L A N ) UPDATED 06/2016

H9115_ MEM0053s Approved 09232015 

MetroPlus FIDA Plan | Lista de Medicamentos Cubiertos 2016 (Formulario) Esta es una lista de los medicamentos que pueden obtener los participantes en MetroPlus FIDA Plan (Plan Medicare-Medicaid).  El MetroPlus FIDA Plan es un plan de atención administrada que tiene contratos con Medicare y el Departamento de Salud del Estado de New York (Medicaid) para proporcionar beneficios de ambos programas a los participantes a través del programa piloto Fully Integrated Duals Advantage (FIDA, por sus siglas en inglés).  La Lista de Medicamentos Cubiertos y/o las redes de farmacias y proveedores pueden cambiar a lo largo del año. Le enviaremos una notificación antes de que hagamos un cambio que le afecte.  Los beneficios pueden cambiar el 1.° de enero de cada año.  Siempre puede consultar la Lista de Medicamentos Cubiertos actualizada de MetroPlus FIDA Plan en www.metroplus.org/fida o llamando a Servicios al Participante de MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY: 711).  Pueden aplicar limitaciones y restricciones. Para más información, llame a Servicios al Participante del MetroPlus FIDA Plan o lea el Manual del Participante del MetroPlus FIDA Plan.  No hay copagos para ningún medicamento cubierto.  Puede obtener esta información en otros formatos sin costo, incluso en letra grande, en Braille o audio. Llame a 1-844-288-FIDA (3432) y al 711 de 8 a. m. a 8 p. m., de lunes a sábado, del 15 de febrero al 30 de septiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita.  El estado de Nueva York ha creado un programa de defensoría del participante llamado Red Independiente de Defensa del Consumidor (Independent Consumer Advocacy Network, ICAN) para proporcionar asistencia gratuita y confidencial a los participantes sobre cualquier servicio ofrecido por el MetroPlus FIDA Plan. Puede comunicarse con la ICAN llamando en forma gratuita al 1-844-614-8800, o en línea en icannys.org.

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Si tiene preguntas, llame a MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY 711) de lunes a viernes de 8 a. m. a 8 p. m. del 15 de febrero al 30 de setiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita. Para más información, visite www.metroplus.org/fida. I 

Preguntas frecuentes Encuentre aquí las respuestas a algunas de las preguntas que quizá tenga sobre la Lista de Medicamentos Cubiertos. Puede leer todas las Preguntas frecuentes para obtener más información o busque una pregunta y su repuesta.

1.

¿Qué medicamentos cubiertos figuran en la Lista de Medicamentos Cubiertos? (Para abreviar, a la Lista de Medicamentos Cubiertos también la llamamos la “Lista de Medicamentos”).

Los medicamentos que figuran en la Lista de Medicamentos Cubiertos que comienza en la página 12 son los medicamentos que cubre el MetroPlus FIDA Plan. Estos medicamentos están disponibles en las farmacias de nuestra red. Una farmacia pertenece a la red si tenemos un contrato con ellos para que trabajen con nosotros y le provean servicios. Nos referimos a estas farmacias como “farmacias de la red”.  MetroPlus FIDA Plan cubrirá todos los medicamentos que figuran en la Lista de Medicamentos si:  su médico u otro profesional que expide la receta dice que usted los necesita para mejorar o conservar su buena salud;  el medicamento es médicamente necesario para su afección; y  usted surte la receta en una farmacia de la red de MetroPlus FIDA Plan.  Es posible que MetroPlus FIDA Plan requiera de pasos adicionales para acceder a determinados medicamentos (consulte la pregunta N.° 5 más abajo). En algunos casos, es posible que deba hacer algo antes de que pueda obtener un medicamento, por ejemplo, probar otro medicamento primero. También puede consultar una lista actualizada de los medicamentos que cubrimos en nuestro sitio web en www.metroplus.org/fida o puede llamar a Servicios al Participante al 1-844-288-FIDA (3432), TTY: 711.

2.

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¿Cambia en algún momento la Lista de Medicamentos?

Si tiene preguntas, llame a MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY 711) de lunes a viernes de 8 a. m. a 8 p. m. del 15 de febrero al 30 de setiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita. Para más información, visite www.metroplus.org/fida. II 

Sí. MetroPlus FIDA Plan puede agregar o quitar medicamentos de la Lista de Medicamentos durante el año. Por lo general, la Lista de Medicamentos solo cambiará si:  sale a la venta un medicamento nuevo que es igual de eficaz que el medicamento que figura actualmente en la Lista de Medicamentos, o  nos enteramos que el medicamento no es seguro. También podemos cambiar las normas sobre los medicamentos. Por ejemplo, podemos:  Decidir que se requiere o no la aprobación previa de un medicamento. (Aprobación previa es un permiso de MetroPlus FIDA Plan o de su Equipo Interdisciplinario (IDT) antes de que usted obtenga un medicamento).  Agregar o cambiar la cantidad de un medicamento que puede obtener (esto se denomina “límites de cantidad”).  Agregar o cambiar restricciones de terapia escalonada de un medicamento. (Terapia escalonada significa que primero debe probar un medicamento antes de cubramos otro medicamento). (Para más información sobre estas normas de medicamentos, consulte la página 5). Si quitamos de la Lista de Medicamentos un medicamento que usted toma, se lo informaremos. También le informaremos cuando cambiemos las normas sobre la cobertura de un medicamento. Las preguntas 3, 4 y 7 que aparecen abajo tienen más información sobre qué sucede cuando cambia la Lista de Medicamentos.  También puede consultar la Lista de Medicamentos de MetroPlus FIDA Plan en línea en www.metroplus.org/fida. Puede llamar a Servicios al Participante al 1-844-288-FIDA (3432), TTY: 711 para consultar la Lista de Medicamentos actual.

3.

¿Qué sucede cuando sale a la venta un medicamento más barato que es igual de eficaz que el medicamento que figura en la Lista de Medicamentos?

Si sale a la venta un medicamento más barato que es igual de eficaz que el medicamento que actualmente figura en la Lista de Medicamentos:

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Si tiene preguntas, llame a MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY 711) de lunes a viernes de 8 a. m. a 8 p. m. del 15 de febrero al 30 de setiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita. Para más información, visite www.metroplus.org/fida. III 

 Su farmacéutico puede darle el medicamento más barato la próxima vez que surta su receta. Si usted y su proveedor deciden que el medicamento más barato no es adecuado para usted, su proveedor puede informarle al farmacéutico que continúe dándole el medicamento que actualmente toma.  MetroPlus FIDA Plan puede decidir quitar el medicamento más caro de la Lista de Medicamentos. Si usted toma un medicamento que nosotros quitamos de la Lista de Medicamentos porque salió a la venta un medicamento más barato que es igual de eficaz, le informaremos con al menos 60 días de antelación acerca de la remoción del medicamento de la Lista de Medicamentos o cuando usted pida unareposición. Luego puede obtener un suministro de 60 días del medicamento antes de que se realice el cambio en la Lista de Medicamentos. Se le notificarán los cambios por escrito, por correo.

4.

¿Qué sucede cuando tomamos conocimiento de que un medicamento no es seguro?

Si la Administración de Alimentos y Medicamentos (FDA, por sus siglas en inglés) informa que un medicamento que usted toma no es seguro, sacaremos el medicamento de la Lista de Medicamentos de inmediato. También le enviaremos una carta y lo llamaremos para informarle que se removió el medicamento inseguro de la Lista de Medicamentos. Puede llamar a Servicios al Participante de MetroPlus FIDA Plan si tiene preguntas sobre estos cambios en la Lista de Medicamentos.

5.

¿Existe alguna restricción o límite en la cobertura de medicamentos? ¿O se requiere de alguna acción para obtener determinados medicamentos?

Sí, algunos medicamentos tienen normas de cobertura o tienen límites sobre la cantidad que usted toma. En algunos casos, usted, su médico u otro profesional que expida la receta deben hacer algo antes de que usted pueda obtener el medicamento. Por ejemplo:  Aprobación previa (o autorización previa): Para algunos medicamentos, usted, su médico u otro profesional que expide la receta deben obtener la aprobación de MetroPlus FIDA Plan o del Equipo Interdisciplinario (IDT) antes de que usted pueda surtir su receta. Si no obtiene esta aprobación, MetroPlus FIDA Plan podría no cubrir el medicamento.

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Si tiene preguntas, llame a MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY 711) de lunes a viernes de 8 a. m. a 8 p. m. del 15 de febrero al 30 de setiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita. Para más información, visite www.metroplus.org/fida. IV 

 Límites de cantidad: En algunas ocasiones, MetroPlus FIDA Plan limita la cantidad del medicamento que puede obtener.  Terapia escalonada: Algunas veces, MetroPlus FIDA Plan requiere que usted haga una terapia escalonada. Esto significa que usted tendrá que probar medicamentos en determinado orden para su afección médica. Es posible que deba probar un medicamento antes de que cubramos otro medicamento. Si su médico cree que el primer medicamento no le resulta eficaz, cubriremos el segundo medicamento. Puede averiguar si su medicamento tiene requisitos adicionales o límites consultando el cuadro que comienza en la página 11. También puede obtener más información visitando nuestra página web en www.metroplus.org/fida. Hemos publicado en Internet documentos que explican nuestras restricciones de autorización previa y terapia escalonada. También puede pedirnos que le enviemos una copia. Usted puede solicitar una “excepción” a estos límites. Consulte la pregunta 11 para obtener más información sobre las excepciones.  Si usted está en un centro de enfermería u otro centro de atención a largo plazo y necesita un medicamento que no figura en la Lista de Medicamentos, o si no puede acceder fácilmente al medicamento que necesita, podemos ayudarlo. Cubriremos un suministro de emergencia de 31 días del medicamento que necesita (a menos que tenga una receta por menos días), independientemente de que sea un participante nuevo en MetroPlus FIDA Plan. Esto le dará tiempo para que hable con su médico u otro profesional que expide recetas. Podrán ayudarlo a decidir si hay un medicamento similar en la Lista de Medicamentos que puede tomar en su lugar o podrá solicitar una excepción. Consulte la pregunta 11 para obtener más información sobre las excepciones.

6.

¿Cómo sabrá si el medicamento que desea tiene limitaciones o si se requieren acciones para obtener el medicamento?

La Lista de Medicamentos Cubiertos que figura en la página 11 tiene una columna llamada “Acciones necesarias, restricciones o límites de uso”.

7.

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¿Qué sucede si cambiamos las normas sobre la cobertura de algunos medicamentos? Por ejemplo, si agregamos autorización

Si tiene preguntas, llame a MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY 711) de lunes a viernes de 8 a. m. a 8 p. m. del 15 de febrero al 30 de setiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita. Para más información, visite www.metroplus.org/fida. V 

previa (aprobación), límites de cantidad, y/o terapia escalonada de un medicamento. Le informaremos si agregamos aprobación previa, límites de cantidad, y/o terapia escalonada de un medicamento. Le informaremos al menos con 60 días de antelación antes de que se agregue la restricción o cuando usted solicite la siguiente reposición. Luego, puede obtener un suministro de 60 días del medicamento antes de que se realice el cambio en la Lista de Medicamentos. Esto le da tiempo para que hable con su médico u otro profesional que expide la receta sobre cómo proseguir.

8.

¿Cómo puede averiguar si un medicamento figura en la Lista de Medicamentos?

Hay dos maneras de encontrar un medicamento:  Puede buscar por orden alfabético (si sabe cómo se escribe el medicamento), o  Puede buscar por afección médica. Para buscar por orden alfabético, consulte la sección Listado alfabético en la página 85. Luego, busque el nombre del medicamento en la lista. Para buscar por afección médica, consulte la sección titulada “Lista de medicamentos por afección médica” en la página 11. Los medicamentos en esta sección están agrupados en categorías dependiendo del tipo de afección médica para los que se utilizan. Por ejemplo, si tiene una enfermedad cardíaca, debe consultar en la categoría Cardiovascular – Medicamentos para tratar afecciones cardíacas y del sistema respiratorio. Allí encontrará los medicamentos que tratan afección cardíacas.

9.

¿Qué sucede si el medicamento que quiere tomar no figura en la Lista de Medicamentos?

Si no ve el medicamento en la Lista de Medicamentos, llame a Servicios al Participante al 1-844288-FIDA (3432), (TTY:711) y pregunte sobre él. Si se enteró de que MetroPlus FIDA Plan no cubrirá el medicamento, puede hacer una de las siguientes cosas:  Pida a Servicios al Participante una lista de medicamentos similares al que desea tomar. Luego muéstrele la lista a su médico u otro profesional que expide recetas. Podrán

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Si tiene preguntas, llame a MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY 711) de lunes a viernes de 8 a. m. a 8 p. m. del 15 de febrero al 30 de setiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita. Para más información, visite www.metroplus.org/fida. VI 

recetarle un medicamento que figure en la Lista de Medicamentos que sea similar al que usted desea tomar. O  Pida al plan o al Equipo Interdisciplinario (IDT) que hagan una excepción en su caso y cubran el medicamento. Consulte la pregunta 11 para obtener más información sobre las excepciones.

10. ¿Qué sucede si usted es un participante nuevo en MetroPlus FIDA

Plan y no puede encontrar su medicamento en la Lista de Medicamentos o tiene un problema para obtener su medicamento? Podemos ayudar. Debemos cubrir hasta 90 días de suministros temporales de su medicamento, según sea necesario, durante los primeros 90 días como participante de MetroPlus FIDA Plan. Esto le dará tiempo para que hable con su médico u otro profesional que expide recetas. Podrán ayudarlo a decidir si hay un medicamento similar en la Lista de Medicamentos que puede tomar en su lugar o podrá solicitar una excepción. Cubriremos hasta 90 días de suministros temporales de su medicamento si:  usted toma un medicamento que no está en nuestra Lista de Medicamentos; o  las normas del plan de salud no le permiten obtener la cantidad que ordenó el profesional que expidió la receta; o  el medicamento requiere una aprobación previa por parte de MetroPlus FIDA Plan o su Equipo Interdisciplinario (IDT); o  usted toma un medicamento que forma parte de una restricción de terapia escalonada. Si usted vive en un centro de enfermería u otro centro de atención a largo plazo, puede obtener una reposición de la receta durante 91 días como máximo. Puede obtener reposiciones adicionales del medicamento durante sus primeros 90 días en el plan. Esto le da al profesional que expide la receta tiempo para cambiar sus medicamentos a otros que figuren en la Lista de Medicamentos o solicitar una excepción. Durante los primeros 90 días de su inscripción en MetroPlus FIDA Plan, nuestra Política de Transición le proporciona por al menos una vez una reposición temporal para 30 días; si su receta es por menos de 30 días, se permiten múltiples reposiciones, a fin de proporcionarle un suministro para 30 días. Asimismo se le permite un suministro de medicamentos para noventa

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Si tiene preguntas, llame a MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY 711) de lunes a viernes de 8 a. m. a 8 p. m. del 15 de febrero al 30 de setiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita. Para más información, visite www.metroplus.org/fida. VII 

(90 días) en caso de que usted solicite una reposición de un medicamento cubierto por Medicaid, que no está incluido en la Parte D. Si usted se encuentra en un establecimiento de atención a largo plazo, MetroPlus FIDA Plan le proveerá un suministro de 98 días, comenzando en los primeros 90 días de inscripción en el plan. Después de los 90 días, le proporcionaremos un suministro de emergencia hasta por 31 días de medicamentos de la Parte D que no figuren en el formulario, mientras está pendiente una determinación de excepción o de autorización previa. Si usted es ingresado o dado de alta de un centro de atención a largo plazo, no se utilizarán modificaciones a la reposición anticipada para limitar el acceso apropiado y necesario a su beneficio, y se le permitirá acceder a una reposición una vez ingresado o dado de alta.

11. ¿Puede solicitar una excepción para que cubramos su

medicamento? Sí. Puede solicitar a MetroPlus FIDA Plan o a su Equipo Interdisciplinario (IDT) que haga una excepción para cubrir un medicamento que no está en la Lista de Medicamentos. También puede solicitarle a MetroPlus FIDA Plan o a su IDT que cambie las normas sobre su medicamento.  En algunas ocasiones, MetroPlus FIDA Plan limita la cantidad del medicamento que cubriremos. Si su medicamento está sujeto a un límite, puede pedirnos a nosotros o a su IDT que cambiemos el límite y cubramos más.  Otros ejemplos: Puede pedirnos a nosotros o a su IDT que dejemos de la lado las restricciones de la terapia escalonada o los requerimientos de la aprobación previa.

12. ¿Cuánto tiempo toma obtener una excepción? En primer lugar, el MetroPlus FIDA Plan o su Equipo Interdisciplinario (IDT) debe recibir una declaración del profesional que expide la receta que respalde su solicitud de una excepción. Después de recibir la declaración, obtendrá una decisión sobre la solicitud de excepción en un plazo de 72 horas. Si usted o el profesional que expide la receta consideran que su salud podría verse perjudicada si espera 72 horas para una decisión, puede pedir una excepción acelerada. Es una decisión más rápida. Si el profesional que expide la receta apoya su solicitud, usted obtendrá una decisión

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Si tiene preguntas, llame a MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY 711) de lunes a viernes de 8 a. m. a 8 p. m. del 15 de febrero al 30 de setiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita. Para más información, visite www.metroplus.org/fida. VIII 

en un plazo de 24 horas posteriores a la recepción de la declaración de respaldo del profesional que expide la receta.

13. ¿Cómo puede solicitar una excepción? Para pedir una excepción, llame a su Administrador de Atención. Su Administrador de Atención trabajará con usted y su proveedor para ayudarle a solicitar una excepción.

14. ¿Qué son los medicamentos genéricos? Los medicamentos genéricos están formados por los mismos ingredientes que los medicamentos de marca. Por lo general, cuestan menos que el medicamento de marca y, a menudo, no tienen nombres reconocidos. Los medicamentos genéricos están aprobados por la Administración de Alimentos y Medicamentos (FDA). MetroPlus FIDA Plan cubre tanto medicamentos genéricos como de marca.

15. ¿Qué son los OTC? OTC son las en inglés de “de venta libre”. El MetroPlus FIDA Plan cubre algunos medicamentos de venta libre (OTC) cuando han sido anotados en una receta por su proveedor. Puede leer la Lista de Medicamentos de MetroPlus FIDA Plan para consultar qué OTC están cubiertos.

16. ¿MetroPlus FIDA Plan cubre productos OTC que no son

medicamentos? El MetroPlus FIDA Plan cubre algunos productos de venta libre (OTC) que no son medicamentos cuando han sido anotados en una receta por su proveedor. Los productos OTC que no son medicamentos incluyen artículos como hisopos impregnados de alcohol y gasas. Puede leer la Lista de Medicamentos de MetroPlus FIDA Plan para consultar qué OTC que no son medicamentos están cubiertos.

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Si tiene preguntas, llame a MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY 711) de lunes a viernes de 8 a. m. a 8 p. m. del 15 de febrero al 30 de setiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita. Para más información, visite www.metroplus.org/fida. IX 

17. ¿Qué es su copago? No se le cobrará un copago por los medicamentos de la Lista de Medicamentos.

18. ¿Qué son los niveles de medicamentos? MetroPlus FIDA Plan tiene tres niveles de medicamentos. Los niveles son grupos de medicamentos. Cada medicamento de la Lista de Medicamentos del plan se encuentra en uno de los tres niveles. Usted no incurre en ningún costo por los medicamentos que se encuentran en cualquiera de los niveles. 

Los medicamentos del Nivel 1 son medicamentos genéricos.



Los medicamentos del Nivel 2 son medicamentos de marca.

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Los medicamentos del Nivel 3 son medicamentos de venta libre y medicamentos recetados cubiertos que no son de Medicare.

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Si tiene preguntas, llame a MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY 711) de lunes a viernes de 8 a. m. a 8 p. m. del 15 de febrero al 30 de setiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita. Para más información, visite www.metroplus.org/fida. X 

Lista de Medicamentos Cubiertos La Lista de Medicamentos Cubiertos que comienza en la próxima página le da información sobre los medicamentos cubiertos por el MetroPlus FIDA Plan. Si tiene dificultades para encontrar su medicamento en la lista, pase al Índice que comienza en la página 85. La primera columna del cuadro lista el nombre del medicamento. Los medicamentos de marca están en mayúscula (por ejemplo, COLCRYS) y los medicamentos genéricos están en minúscula y cursiva (por ejemplo, penicilina). La información en la columna Acciones necesarias, restricciones o límites de uso le informa si MetroPlus FIDA Plan tiene algún requerimiento para la cobertura de su medicamento. Nota: El * junto a un medicamento significa que el medicamento no es un “medicamento de la Parte D”. Estos medicamentos tienen normas diferentes para las apelaciones. Una apelación es una manera formal de solicitar una revisión y un cambio de una decisión de cobertura si considera que fue un error. Por ejemplo, MetroPlus FIDA Plan o su Equipo Interdisciplinario (IDT) podrían decidir que un medicamento que usted desea no está cubierto o que ya no lo cubre Mediare o Medicaid. Si usted, su médico u otro profesional que expide la receta no están de acuerdo con la decisión, usted puede apelar. Para solicitar instrucciones sobre cómo apelar, llame a Servicios al Participante al 1-844-288-FIDA (3432) (TTY: 711) o a la Red Independiente de Defensa del Consumidor (Independent Consumer Advocacy Network, ICAN) al 1-844-6148800. También puede leer el Manual del Participante para obtener información sobre cómo apelar una decisión.

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Si tiene preguntas, llame a MetroPlus FIDA Plan al 1-844-288-FIDA (3432) (TTY 711) de lunes a viernes de 8 a. m. a 8 p. m. del 15 de febrero al 30 de setiembre, y de 8 a. m. a 8 p. m., los 7 días de la semana, del 1.° de octubre al 14 de febrero. Después de las 8 p. m., los domingos y días festivos, llame al Servicio de Recepción de Llamadas Médicas disponible las 24 horas del día, los 7 días de la semana, al 1-800-442-2560. La llamada es gratuita. Para más información, visite www.metroplus.org/fida. XI 

NY_MMP_CY16_2T_STND eff 06/01/2016 Drug Name

Drug Tier

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU

ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION GOUT - DRUGS TO TREAT GOUT allopurinol tab colchicine w/ probenecid COLCRYS probenecid ULORIC

1 1 2 1 2

$0 $0 $0 $0 $0

QL (120 tabs / 30 days)

3 3 3 3 3

$0 $0 $0 $0 $0

NM; NM; NM; NM; NM;

* * * * *

3 3 3 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * *

3

$0

NM; *

3 3 3 3 3

$0 $0 $0 $0 $0

NM; NM; NM; NM; NM;

* * * * *

3 3 3 3 3

$0 $0 $0 $0 $0

NM; NM; NM; NM; NM;

* * * * *

ST

MISCELLANEOUS acetaminophen CHEW acetaminophen LIQD acetaminophen SOLN ACETAMINOPHEN SUPP 120mg acetaminophen SUPP 325mg, 650mg acetaminophen SUSP acetaminophen TABS acetaminophen TBCR acetaminophen TBDP ACETAMINOPHEN 8 HOUR APAP 500 aspirin SUPP 300mg, 600mg aspirin TABS aspirin TBEC 325mg, 500mg, 650mg aspirin buffered (cal carb-mag carb-mag oxide) FEBROL FEVERALL INFANTS ibuprofen CAPS ibuprofen CHEW ibuprofen SUSP 50mg/1.25ml, 100mg/5ml IBUPROFEN TABS 100mg ibuprofen TABS 200mg NAPROXEN SODIUM CAPS naproxen sodium TABS 220mg TRIAMINIC FEVER REDUCER P

NSAIDS - DRUGS TO TREAT PAIN AND INFLAMMATION celecoxib CAPS diclofenac potassium

1 1

$0 $0

QL (60 caps / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

1

Drug Name

Drug Tier

diclofenac sodium TB24 diclofenac sodium TBEC diflunisal etodolac etodolac er flurbiprofen TABS ibuprofen SUSP 100mg/5ml ibuprofen TABS 400mg, 600mg, 800mg ketoprofen CAPS MELOXICAM SUSP meloxicam TABS nabumetone TABS naproxen SUSP; TABS; TBEC naproxen sodium TABS 275mg, 550mg piroxicam CAPS sulindac TABS

1 1 1 1 1 1 1 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0 $0

1 1 1 1 1 1

$0 $0 $0 $0 $0 $0

1 1

$0 $0

OPIOID ANALGESICS - DRUGS TO TREAT PAIN acetaminophen w/ codeine SOLN 1 acetaminophen w/ codeine TABS 1 butorphanol tartrate SOLN 1 1mg/ml, 2mg/ml nalbuphine hcl SOLN 1 tramadol hcl TABS 1 tramadol-acetaminophen 1

$0 $0 $0 $0 $0 $0

QL (5000 mL / 30 days) QL (400 tabs / 30 days)

QL (240 tabs / 30 days) QL (240 tabs / 30 days)

OPIOID ANALGESICS, CII - DRUGS TO TREAT PAIN DURAMORPH endocet fentanyl citrate

1 1 2

$0 $0 $0

fentanyl patch 12 mcg/hr

1

$0

fentanyl patch 25 mcg/hr

1

$0

fentanyl patch 50 mcg/hr

1

$0

fentanyl patch 75 mcg/hr

1

$0

fentanyl patch 100 mcg/hr

1

$0

FENTORA

2

$0

LPOP

B/D QL (360 tabs / 30 days) QL (120 lozenges / 30 days), PA QL (10 patches / 30 days) QL (10 patches / 30 days) QL (10 patches / 30 days), PA QL (10 patches / 30 days), PA QL (10 patches / 30 days), PA QL (120 tabs / 30 days), PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

2

Drug Name

Drug Tier

hydroco/apap tab 5-325mg 1 hydroco/apap tab 7.5-325 1 hydroco/apap tab 10-325mg 1 hydrocodone-acetaminophen 1 7.5-325 mg/15ml hydrocodone-ibuprofen tab 7.5-2001 mg hydromorphon inj 10mg/ml 1 hydromorphone hcl LIQD 1 hydromorphone hcl TABS 1 lorcet hd tab 10-325mg 1 lorcet plus tab 7.5-325 1 lorcet tab 5-325mg 1 lortab tab 5-325mg 1 lortab tab 7.5-325 1 lortab tab 10-325mg 1 methadone hcl CONC 1 methadone hcl SOLN 5mg/5ml, 1 10mg/5ml methadone hcl TABS 1 morphine ext-rel tab 15mg, 1 30mg, 60mg, 100mg morphine ext-rel tab 200mg 1 MORPHINE SUL INJ 1MG/ML 1 MORPHINE SUL INJ 4MG/ML 1 MORPHINE SUL INJ 10MG/ML 1 MORPHINE SUL INJ 15MG/ML 1 morphine sulfate CP24 10mg, 1 20mg, 30mg, 50mg, 60mg morphine sulfate CP24 80mg 2 MORPHINE SULFATE SOLN 1 2mg/ml, 8mg/ml morphine sulfate SOLN .5mg/ml, 1 1mg/ml, 4mg/ml, 8mg/ml MORPHINE SULFATE TABS 1 morphine sulfate beads 1 morphine sulfate cap 100mg er 2 MORPHINE SULFATE ORAL SOL 1 oxycodone hcl CAPS 1 oxycodone hcl CONC 1 OXYCODONE HCL SOLN 1 oxycodone hcl TABS 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (360 tabs / 30 days) $0 QL (360 tabs / 30 days) $0 QL (360 tabs / 30 days) $0 QL (5400 mL / 30 days) $0

QL (150 tabs / 30 days)

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

B/D

$0 $0

QL (240 tabs / 30 days) QL (90 tabs / 30 days)

$0 $0 $0 $0 $0 $0

QL (60 tabs / 30 days) B/D B/D B/D B/D QL (60 caps / 30 days)

$0 $0

QL (60 caps / 30 days) B/D

$0

B/D

$0 $0 $0 $0 $0 $0 $0 $0

QL (180 tabs / 30 days) QL (60 caps / 30 days) QL (60 caps / 30 days)

QL QL QL QL QL QL QL QL QL

(270 (360 (360 (360 (360 (360 (360 (120 (600

tabs / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days) tabs / 30 days) mL / 30 days) mL / 30 days)

QL (180 caps / 30 days)

QL (180 tabs / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

3

Drug Name

oxycodone w/ acetaminophen 2.5-325mg oxycodone w/ acetaminophen 5-325mg oxycodone w/ acetaminophen 7.5-325mg oxycodone w/ acetaminophen 10-325mg roxicet soln roxicet tab 5-325mg

Drug Tier 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (360 tabs / 30 days)

1

$0

QL (360 tabs / 30 days)

1

$0

QL (360 tabs / 30 days)

1

$0

QL (360 tabs / 30 days)

2 1

$0 $0

QL (1800 mL / 30 days) QL (360 tabs / 30 days)

$0 $0 $0 $0 $0

B/D B/D B/D B/D B/D

ANESTHETICS - DRUGS FOR NUMBING LOCAL ANESTHETICS lidocaine lidocaine lidocaine lidocaine lidocaine

hcl (local anesth.) inj 0.5% inj 1% inj 1.5% inj 2%

1 1 1 1 1

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN gentamicin in saline gentamicin sulfate SOLN neomycin sulfate TABS paromomycin sulfate CAPS streptomycin sulfate SOLR sulfadiazine TABS tobramycin NEBU tobramycin sulfate SOLN; SOLR

1 1 1 1 1 1 2 2 1

$0 $0 $0 $0 $0 $0 $0 $0 $0

B/D, NM

ANTI-INFECTIVES - MISCELLANEOUS ALBENZA ALINIA atovaquone SUSP AZACTAM/DEX INJ 1GM AZACTAM/DEX INJ 2GM aztreonam BILTRICIDE CAYSTON clindamycin cap 75mg clindamycin cap 300mg clindamycin hcl cap 150 mg clindamycin phosphate SOLN clindamycin phosphate in d5w

2 2 2 2 2 1 2 2 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM, LA, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

4

Drug Name

Drug Tier

clindamycin phosphate inj 1 clindamycin sol 75mg/5ml 1 colistimethate sodium SOLR 1 CUBICIN 2 dapsone TABS 1 DARAPRIM 2 imipenem-cilastatin 1 INVANZ 2 ivermectin TABS 1 linezolid SOLN 2 LINEZOLID SUSR; TABS 2 LINEZOLID IN SODIUM CHLORIDE 2 meropenem 1 methenamine hippurate 1 metronidazole TABS 1 metronidazole in nacl 1 NEBUPENT 2 nitrofurantoin macrocrystal 50mg,2 100mg nitrofurantoin monohyd macro

2

PENTAM 300 2 SIVEXTRO 2 sulfamethoxazole-trimethoprim 1 sulfamethoxazole-trimethoprim inj 1 SYNERCID 2 trimethoprim TABS 1 TYGACIL 2 vancomycin hcl CAPS 2 vancomycin hcl SOLR 1 ZYVOX TABS 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 B/D $0 PA; PA applies if 65 years and older after a 90 day supply in a calendar year $0 PA; PA applies if 65 years and older after a 90 day supply in a calendar year $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

ANTIFUNGALS - DRUGS TO TREAT FUNGAL INFECTIONS ABELCET AMBISOME amphotericin b SOLR CANCIDAS fluconazole SUSR; TABS fluconazole in dextrose

2 2 1 2 1 1

$0 $0 $0 $0 $0 $0

B/D B/D B/D

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

5

Drug Name

fluconazole in nacl flucytosine CAPS griseofulvin microsize griseofulvin ultramicrosize itraconazole CAPS ketoconazole TABS MYCAMINE NOXAFIL SUSP; TBEC nystatin TABS terbinafine hcl TABS voriconazole SOLR voriconazole SUSR; TABS

Drug Tier 1 2 1 1 1 1 2 2 1 1 1 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 PA $0 PA $0 $0 $0 $0 QL (90 tabs / 365 days) $0 $0

ANTIMALARIALS - DRUGS TO TREAT MALARIA atovaquone-proguanil hcl chloroquine phosphate TABS COARTEM mefloquine hcl PRIMAQUINE PHOSPHATE quinine sulfate CAPS

1 1 2 1 2 1

$0 $0 $0 $0 $0 $0

PA

ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate APTIVUS CRIXIVAN didanosine EDURANT EMTRIVA FUZEON INTELENCE INVIRASE ISENTRESS lamivudine LEXIVA NEVIRAPINE SUSP nevirapine TABS; TB24 NORVIR PREZISTA RESCRIPTOR RETROVIR IV INFUSION REYATAZ SELZENTRY

1 2 2 1 2 2 2 2 2 2 1 2 1 1 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

6

Drug Name

stavudine SUSTIVA TIVICAY TYBOST VIDEX PEDIATRIC VIRACEPT VIRAMUNE XR 100mg VIREAD VITEKTA ZIAGEN SOLN zidovudine

Drug Tier 1 2 2 2 2 2 2 2 2 2 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

ANTIRETROVIRAL COMBINATION AGENTS - DRUGS TO SUPPRESS HIV/AIDS INFECTION abacavir sulfate-lamivudine-zidovudine ATRIPLA COMPLERA EPZICOM EVOTAZ GENVOYA KALETRA SOL KALETRA TAB 100-25MG KALETRA TAB 200-50MG lamivudine-zidovudine PREZCOBIX STRIBILD TRIUMEQ TRUVADA

2

$0

2 2 2 2 2 2 2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

QL (30 tabs / 30 days)

ANTITUBERCULAR AGENTS - DRUGS TO TREAT TUBERCULOSIS CAPASTAT SULFATE cycloserine CAPS ethambutol hcl TABS isoniazid TABS isoniazid inj 100 mg/ml isoniazid syp 50mg/5ml paser d/r PRIFTIN pyrazinamide TABS rifabutin rifampin CAPS; SOLR RIFATER SIRTURO

2 2 1 1 1 1 2 2 1 1 1 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

LA, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

7

Drug Name

TRECATOR

Drug Tier 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0

ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS acyclovir CAPS; SUSP; TABS acyclovir sodium SOLN acyclovir sodium SOLR 500mg adefovir dipivoxil BARACLUDE SOLN DAKLINZA entecavir EPIVIR HBV SOLN famciclovir TABS ganciclovir inj 500mg HARVONI lamivudine (hbv) moderiba 800 dose pack moderiba pak 600/day moderiba pak 1000/day MODERIBA PAK 1200/DAY moderiba tab 200mg PEG-INTRON REDIPEN PEGASYS PEGASYS PROCLICK PEGINTRON REBETOL SOLN RELENZA DISKHALER ribapak mis 600/day ribasphere CAPS ribasphere TABS 200mg, 400mg ribasphere TABS 600mg ribasphere ribapak 800 ribasphere ribapak 1000 ribasphere ribapak 1200 ribavirin 200mg rimantadine hydrochloride SOVALDI TAMIFLU TYZEKA valacyclovir hcl TABS VALCYTE SOLR valganciclovir hcl

1 1 1 2 2 2 2 2 1 1 2 1 2 2 2 2 1 2 2 2 2 2 2 2 1 1 2 2 2 2 1 1 2 2 2 1 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

B/D B/D

NM, PA

B/D NM, PA NM NM NM NM NM NM, NM, NM, NM, NM

PA PA PA PA

NM NM NM NM NM NM NM NM NM, PA

CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS cefaclor

1

$0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

8

Drug Name

Drug Tier

cefaclor monohydrate er 2 cefadroxil 1 cefazolin in dextrose 1gm/50ml-5%2 CEFAZOLIN IN DEXTROSE 2 2GM/100ML-4% cefazolin inj 1 cefazolin sodium 1gm, 20gm 1 cefdinir 1 cefepime hcl 1 cefixime 1 cefotaxime sodium 1gm, 2gm, 1 500mg cefoxitin sodium 1 cefpodoxime proxetil 1 cefprozil 1 ceftazidime 1 CEFTAZIDIME/DEXTROSE 2 ceftriaxone sodium SOLR 1gm, 1 2gm, 10gm, 250mg, 500mg cefuroxime axetil 1 cefuroxime sodium 1.5gm, 7.5gm,1 750mg cephalexin CAPS 250mg, 500mg 1 cephalexin SUSR 1 SUPRAX CAPS 2 suprax CHEW 2 SUPRAX SUSR 500mg/5ml 2 tazicef SOLR 1 tazicef vial 1 TEFLARO 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

ERYTHROMYCINS/MACROLIDES - DRUGS TO TREAT INFECTIONS AZITHROMYCIN PACK 1 azithromycin SOLR; SUSR; TABS 1 clarithromycin TABS 1 clarithromycin er 1 clarithromycin for susp 1 DIFICID 2 e.e.s. 1 ery-tab 1 erythrocin lactobionate 2 erythrocin stearate 1 erythromycin base 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

9

Drug Name

Drug Tier

erythromycin cap 250mg ec erythromycin ethylsuccinate

1 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0

FLUOROQUINOLONES - DRUGS TO TREAT INFECTIONS ciprofloxacin SUSR ciprofloxacin er ciprofloxacin hcl tab ciprofloxacin in d5w ciprofloxacin inj ciprofloxacn inj 400mg/40ml levofloxacin TABS levofloxacin in d5w levofloxacin inj 25mg/ml levofloxacin oral soln 25 mg/ml

1 1 1 1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

PENICILLINS - DRUGS TO TREAT INFECTIONS amoxicillin amoxicillin & pot clavulanate ampicillin & sulbactam sodium ampicillin cap 250 mg ampicillin cap 500 mg ampicillin for susp 125 mg/5ml ampicillin for susp 250 mg/5ml ampicillin inj ampicillin sodium BICILLIN L-A dicloxacillin sodium nafcillin sodium 1gm nafcillin sodium 2gm, 10gm oxacillin sodium 1gm, 2gm oxacillin sodium 10gm PENICILLIN G POT IN DEXTROSE penicillin g procaine penicillin g sodium penicillin v potassium penicilln gk inj 5mu penicilln gk inj 20mu piperacillin sodium-tazobactam sodium

1 1 1 1 1 1 1 1 1 2 1 1 2 1 2 2 2 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

TETRACYCLINES - DRUGS TO TREAT INFECTIONS doxy doxycycline (monohydrate) 50mg, 100mg doxycycline (monohydrate)

1 CAPS 1

$0 $0

TABS 1

$0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

10

Drug Name

Drug Tier

doxycycline hyclate CAPS; SOLR; 1 TABS minocycline hcl CAPS 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0

ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER ALKYLATING AGENTS BENDEKA BICNU BUSULFEX CYCLOPHOSPHAMIDE CAPS cyclophosphamide SOLR 1gm, 500mg cyclophosphamide SOLR 2gm dacarbazine EMCYT GLEOSTINE HEXALEN IFEX INJ 3GM ifosfamide inj 1gm ifosfamide inj 1gm/20ml IFOSFAMIDE INJ 3GM ifosfamide inj 3gm/60ml LEUKERAN melphalan hcl MUSTARGEN TREANDA

2 2 2 2 2

$0 $0 $0 $0 $0

B/D, NM B/D B/D B/D B/D

1 1 2 2 2 2 1 1 2 1 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

B/D B/D

1 1 2

$0 $0 $0

B/D B/D B/D

1 1 2

$0 $0 $0

B/D B/D B/D

1 1

$0 $0

B/D B/D

1 2 2 2 1

$0 $0 $0 $0 $0

B/D B/D B/D, NM B/D B/D

B/D B/D B/D B/D B/D B/D B/D B/D, NM

ANTHRACYCLINES daunorubicin hcl doxorubicin hcl for inj 50 mg doxorubicin hcl liposomal inj 2mg/ml doxorubicin inj 50mg epirubicin hcl idarubicin hcl

ANTIBIOTICS bleomycin sulfate mitomycin SOLR

ANTIMETABOLITES adrucil ALIMTA azacitidine cladribine cytarabine 20mg/ml

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

11

Drug Name

fludarabine phosphate fluorouracil SOLN GEMCITABINE HCL SOLN gemcitabine hcl SOLR mercaptopurine TABS METHOTREXATE SODIUM 50mg/2ml methotrexate sodium 50mg/2ml, 100mg/4ml, 200mg/8ml, 250mg/10ml methotrexate sodium inj NIPENT PURIXAN TABLOID

Drug Tier 1 1 2 2 1 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 B/D $0 B/D $0 B/D $0 B/D $0 $0 B/D

1

$0

B/D

1 2 2 2

$0 $0 $0 $0

B/D B/D NM

2 2

$0 $0

B/D B/D

2 1 2

$0 $0 $0

B/D B/D B/D

2 1

$0 $0

B/D B/D

$0 $0 $0 $0

B/D B/D B/D B/D

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

B/D, NM, LA NM, PA NM, LA, PA NM, LA, PA B/D, NM NM, LA, PA B/D, NM B/D, NM NM, PA NM, LA, PA NM, PA B/D, NM

ANTIMITOTIC, TAXOIDS ABRAXANE DOCETAXEL CONC 20mg/ml, 80mg/4ml docetaxel CONC 140mg/7ml DOCETAXEL SOLN 20mg/2ml DOCETAXEL SOLN 160mg/16ml, 200mg/20ml DOCETAXEL SOLN 80MG/8ML paclitaxel

ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate vincasar vincristine sulfate vinorelbine tartrate

2 1 1 1

BIOLOGIC RESPONSE MODIFIERS AVASTIN BELEODAQ ERIVEDGE FARYDAK HERCEPTIN IBRANCE ISTODAX KADCYLA KEYTRUDA LYNPARZA NINLARO PROLEUKIN

2 2 2 2 2 2 2 2 2 2 2 2

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

12

Drug Name

RITUXAN VELCADE YERVOY ZOLINZA

Drug Tier 2 2 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM, LA, PA $0 B/D, NM $0 NM, PA $0 NM, PA

HORMONAL ANTINEOPLASTIC AGENTS anastrozole TABS bicalutamide DEPO-PROVERA INJ 400/ML exemestane FARESTON FASLODEX flutamide letrozole TABS leuprolide acetate KIT LUPRON DEP-PED INJ 7.5MG LUPRON DEP-PED INJ 11.25MG LUPRON DEP-PED INJ 15MG LUPRON DEP-PED INJ 30MG (3-MONTH) LUPRON DEPOT 3.75mg LUPRON DEPOT INJ 11.25 MG LYSODREN megestrol ac sus 40mg/ml

1 1 2 1 2 2 1 1 1 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

2 2 2 2

$0 $0 $0 $0

megestrol ac tab 20mg

2

$0

megestrol ac tab 40mg

2

$0

MEGESTROL SUS 625MG/5ML NILANDRON SOLTAMOX tamoxifen citrate TABS TRELSTAR DEP INJ 3.75MG TRELSTAR LA INJ 11.25MG XTANDI ZYTIGA

2 2 2 1 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0

2 2 2 2 2

$0 $0 $0 $0 $0

B/D

B/D

NM, NM, NM, NM, NM,

PA PA PA PA PA

NM, PA NM, PA PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older PA

NM, NM, NM, NM,

PA PA LA, PA LA, PA

NM, NM, NM, NM, NM,

PA PA LA, PA PA LA, PA

KINASE INHIBITORS AFINITOR AFINITOR DISPERZ ALECENSA BOSULIF CAPRELSA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

13

Drug Name

COMETRIQ COTELLIC GILOTRIF TAB 20MG GILOTRIF TAB 30MG GILOTRIF TAB 40MG ICLUSIG imatinib mesylate IMBRUVICA CAP 140MG INLYTA IRESSA JAKAFI LENVIMA 10MG DAILY DOSE LENVIMA 14MG DAILY DOSE LENVIMA 20MG DAILY DOSE LENVIMA 24MG DAILY DOSE MEKINIST NEXAVAR SPRYCEL STIVARGA SUTENT TAFINLAR TAGRISSO TARCEVA TASIGNA TYKERB VOTRIENT XALKORI ZELBORAF ZYDELIG ZYKADIA

Drug Tier 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, PA $0 NM, LA, PA $0 NM, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA $0 NM, LA, PA

2 2 1 2 2 1 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

MISCELLANEOUS bexarotene DROXIA hydroxyurea CAPS LONSURF MATULANE mitoxantrone hcl ODOMZO POMALYST CAP 1MG POMALYST CAP 2MG POMALYST CAP 3MG POMALYST CAP 4MG

NM, PA

NM, PA LA B/D, NM NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA NM, LA, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

14

Drug Name

SYLATRON KIT 200MCG SYLATRON KIT 300MCG SYLATRON KIT 600MCG SYNRIBO tretinoin (chemotherapy) TRISENOX

Drug Tier 2 2 2 2 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM, PA $0 NM, PA $0 NM, PA $0 NM, PA $0 $0 B/D

1 1 2

$0 $0 $0

B/D B/D B/D

2 2 2 2 1 1 1 2 1 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

B/D B/D B/D B/D, NM B/D

1 1 1 1 1 2

$0 $0 $0 $0 $0 $0

B/D B/D B/D B/D B/D B/D

PLATINUM-BASED AGENTS carboplatin cisplatin oxaliplatin

PROTECTIVE AGENTS amifostine crystalline dexrazoxane 250mg ELITEK FUSILEV leucovorin calcium SOLR leucovorin calcium TABS leucovorin calcium for inj 500 mg levoleucovorin calcium mesna MESNEX TABS

B/D B/D, NM B/D

TOPOISOMERASE INHIBITORS etoposide SOLN 500mg/25ml irinotecan inj 40mg/2ml irinotecan inj 100/5ml irinotecan inj 500mg/25ml toposar 1gm/50ml topotecan hcl SOLR

CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine--benazepril hcl cap 1 10-20 mg amlodipine-benazepril hcl cap 1 2.5-10 mg amlodipine-benazepril hcl cap 5-10 1 mg amlodipine-benazepril hcl cap 5-20 1 mg amlodipine-benazepril hcl cap 5-40 1 mg

$0

QL (30 caps / 30 days)

$0

QL (30 caps / 30 days)

$0

QL (30 caps / 30 days)

$0

QL (30 caps / 30 days)

$0

QL (30 caps / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

15

Drug Name

Drug Tier

amlodipine-benazepril hcl cap 10-40mg benazepril & hydrochlorothiazide captopril & hydrochlorothiazide enalapril maleate & hydrochlorothiazide fosinopril sodium & hydrochlorothiazide lisinopril & hydrochlorothiazide moexipril-hydrochlorothiazide quinapril-hydrochlorothiazide

1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0

1 1 1

$0 $0 $0

1

$0

1 1 1

$0 $0 $0

ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD PRESSURE benazepril hcl TABS captopril TABS enalapril maleate TABS fosinopril sodium lisinopril TABS moexipril hcl perindopril erbumine quinapril hcl ramipril trandolapril

1 1 1 1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE eplerenone spironolactone TABS

1 1

$0 $0

ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE doxazosin mesylate 4mg doxazosin mesylate prazosin hcl terazosin hcl

1mg, 2mg,

1

$0

8mg

1 1 1

$0 $0 $0

QL (30 tabs / 30 days)

ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE amlodipine besylate-valsartan 5-160 mg amlodipine besylate-valsartan 5-320 mg amlodipine besylate-valsartan 10-160 mg amlodipine besylate-valsartan 10-320 mg

tab 1

$0

QL (30 tabs / 30 days)

tab 1

$0

QL (30 tabs / 30 days)

tab 1

$0

QL (30 tabs / 30 days)

tab 1

$0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

16

Drug Name

amlodipine-valsartan-hydrochlorot hiazide 5-160-12.5mg amlodipine-valsartan-hydrochlorot hiazide 5-160-25mg amlodipine-valsartan-hydrochlorot hiazide 10-160-12.5mg amlodipine-valsartan-hydrochlorot hiazide 10-160-25mg amlodipine-valsartan-hydrochlorot hiazide 10-320-25mg AZOR 10-40MG AZOR TAB 5-20MG AZOR TAB 5-40MG AZOR TAB 10-20MG BENICAR HCT 40-25MG BENICAR HCT TAB 20-12.5MG BENICAR HCT TAB 40-12.5MG ENTRESTO irbesartan-hydrochlorothiazide losartan-hydrochlorothiazide TRIBENZOR TAB 20-5-12.5MG TRIBENZOR TAB 40-5-12.5MG TRIBENZOR TAB 40-5-25MG TRIBENZOR TAB 40-10-12.5 TRIBENZOR TAB 40-10-25MG valsartan & hctz tab 80-12.5mg valsartan & hctz tab 160-12.5mg valsartan & hctz tab 160-25mg valsartan & hctz tab 320-12.5mg valsartan & hctz tab 320-25mg

Drug Tier 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (30 tabs / 30 days)

1

$0

QL (60 tabs / 30 days)

1

$0

QL (30 tabs / 30 days)

1

$0

QL (30 tabs / 30 days)

1

$0

2 2 2 2 2 2 2 2 1 1 2 2 2 2 2 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

QL (30 tabs / 30 days) QL (30 tabs / 30 days) QL (30 tabs / 30 days)

PA

QL QL QL QL

(30 (30 (30 (30

tabs tabs tabs tabs

/ / / /

30 30 30 30

days) days) days) days)

ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS TO TREAT HIGH BLOOD PRESSURE BENICAR irbesartan losartan potassium valsartan

2 1 1 1

$0 $0 $0 $0

ANTIARRHYTHMICS - DRUGS TO CONTROL HEART RHYTHM amiodarone hcl disopyramide phosphate

1 2

$0 $0

flecainide acetate mexiletine hcl

1 1

$0 $0

PA; PA if 65 years and older

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

17

Drug Name

Drug Tier

MULTAQ NORPACE CR

2 2

pacerone propafenone hcl propafenone hcl 12hr quinidine gluconate TBCR quinidine sulfate TABS sorine sotalol hcl sotalol hcl (afib/afl) TIKOSYN

1 1 1 1 1 1 1 1 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 PA; PA if 65 years and older $0 $0 $0 $0 $0 $0 $0 $0 $0 NM

ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS - DRUGS TO TREAT HIGH CHOLESTEROL atorvastatin calcium CRESTOR lovastatin 10mg lovastatin 20mg lovastatin 40mg pravastatin sodium simvastatin TABS

TABS

1 2 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0

QL QL QL QL QL QL QL

(30 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days)

ANTILIPEMICS, MISCELLANEOUS - DRUGS TO TREAT HIGH CHOLESTEROL cholestyramine cholestyramine light choline fenofibrate colestipol hcl fenofibrate TABS 48mg, 54mg, 145mg, 160mg fenofibrate micronized 67mg, 134mg, 200mg gemfibrozil TABS JUXTAPID KYNAMRO niacin er (antihyperlipidemic) 500mg niacin er (antihyperlipidemic) 750mg, 1000mg niacor omega-3-acid ethyl esters PRALUENT prevalite

1 1 1 1 1

$0 $0 $0 $0 $0

1

$0

1 2 2 1

$0 $0 $0 $0

1

$0

1 1 2 1

$0 $0 $0 $0

NM, LA, PA NM, PA QL (90 tabs / 30 days)

NM, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

18

Drug Name

VASCEPA WELCHOL ZETIA TAB 10MG

Drug Tier 2 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0

BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS atenolol & chlorthalidone bisoprolol & hydrochlorothiazide metoprolol & hctz tab 50-25mg metoprolol & hctz tab 100-25mg metoprolol & hctz tab 100-50mg propranolol & hydrochlorothiazide

1 1 1 1 1 1

$0 $0 $0 $0 $0 $0

BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS acebutolol hcl CAPS 1 atenolol TABS 1 bisoprolol fumarate 1 BYSTOLIC 2 carvedilol 1 labetalol hcl TABS 1 metoprolol succinate 25mg, 50mg 1 metoprolol succinate 100mg 1 metoprolol succinate 200mg 1 metoprolol tartrate SOLN 1 metoprolol tartrate TABS 25mg, 1 50mg, 100mg nadolol TABS 1 pindolol 1 propranolol cap er 1 propranolol hcl SOLN; TABS 1 timolol maleate TABS 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

QL (60 tabs / 30 days) QL (45 tabs / 30 days)

$0 $0 $0 $0 $0

CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT HIGH BLOOD PRESSURE AND HEART CONDITIONS afeditab cr 30mg 1 afeditab cr 60mg 1 amlodipine besylate TABS 2.5mg, 1 5mg amlodipine besylate TABS 10mg 1 cartia xt cap 120/24hr 1 cartia xt cap 180/24hr 1 cartia xt cap 240/24hr 1 cartia xt cap 300/24hr 1

$0 $0 $0

QL (60 tabs / 30 days) QL (45 tabs / 30 days)

$0 $0 $0 $0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

19

Drug Name

Drug Tier

dilt-xr cap diltiazem cap diltiazem cap 120mg/24hr diltiazem cap 240mg/24hr diltiazem cap er/12hr diltiazem hcl SOLN; TABS diltiazem hcl coated beads CP24 felodipine 2.5mg felodipine 5mg felodipine 10mg isradipine nicardipine hcl CAPS nifedical 30mg nifedical 60mg nifedipine TB24 30mg nifedipine TB24 60mg, 90mg nifedipine er 30mg nifedipine er 60mg, 90mg nimodipine CAPS NYMALIZE taztia verapamil cap er 100mg, 120mg, 180mg, 200mg, 240mg, 300mg VERAPAMIL CAP ER 360mg verapamil hcl SOLN; TABS; TBCR verapamil tab er

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0 $0 QL (30 tabs / 30 days) $0 QL (60 tabs / 30 days) $0 $0 $0 $0 QL (30 tabs / 30 days) $0 $0 QL (60 tabs / 30 days) $0 $0 QL (30 tabs / 30 days) $0 $0 $0 $0 $0

1 1 1

$0 $0 $0

DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART CONDITIONS digitek

.25mg

1

$0

digitek .125mg digox 125mcg digox 250mcg

1 1 1

$0 $0 $0

digoxin digoxin

1 1

$0 $0

1 1

$0 $0

TABS 125mcg TABS 250mcg

digoxin inj DIGOXIN SOL 50MCG/ML

PA; PA older QL (30 QL (30 PA; PA older QL (30 PA; PA older

if 65 years and tabs / 30 days) tabs / 30 days) if 65 years and tabs / 30 days) if 65 years and

PA; PA if 65 years and older

DIRECT RENIN INHIBITORS/COMBINATIONS - DRUGS TO TREAT HEART CONDITIONS TEKTURNA

150mg

2

$0

QL (30 tabs / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

20

Drug Name

TEKTURNA TEKTURNA TEKTURNA TEKTURNA TEKTURNA

300mg HCT TAB HCT TAB HCT TAB HCT TAB

Drug Tier

150-12.5MG 150-25MG 300-12.5MG 300-25MG

2 2 2 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 QL (30 tabs / 30 days) $0 QL (60 tabs / 30 days) $0 QL (30 tabs / 30 days) $0

DIURETICS - DRUGS TO TREAT HEART CONDITIONS acetazolamide CP12; TABS amiloride & hydrochlorothiazide amiloride hcl TABS bumetanide chlorothiazide tabs chlorthalidone 25mg, 50mg furosemide SOLN; TABS furosemide inj 10mg/ml FUROSEMIDE INJ 10mg/ml hydrochlorothiazide CAPS; TABS indapamide methazolamide TABS methyclothiazide metolazone spironolactone & hydrochlorothiazide torsemide inj torsemide tabs triamterene & hydrochlorothiazide TABS triamterene & hydrochlorothiazide cap 37.5-25 mg

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

1 1 1

$0 $0 $0

1

$0

1 2 1 1 1 2

$0 $0 $0 $0 $0 $0

MISCELLANEOUS clonidine hcl PTWK; TABS DEMSER hydralazine hcl SOLN; TABS midodrine hcl minoxidil TABS RANEXA

NITRATES - DRUGS TO TREAT HEART CONDITIONS isosorb mononitrate tab isosorbide dinitrate isosorbide dinitrate er isosorbide mononitrate er minitran nitro-bid

1 1 1 1 1 2

$0 $0 $0 $0 $0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

21

Drug Name

Drug Tier

NITRO-DUR DIS 0.3MG/HR NITRO-DUR DIS 0.8MG/HR nitroglycerin PT24 NITROSTAT

2 2 1 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0

PULMONARY ARTERIAL HYPERTENSION - DRUGS TO TREAT PULMONARY HYPERTENSION ADEMPAS

2

$0

LETAIRIS

2

$0

OPSUMIT

2

$0

REMODULIN REVATIO SUSR

2 2

$0 $0

sildenafil citrate (pulmonary hypertension) TABS TRACLEER 62.5mg

1

$0

2

$0

TRACLEER

2

$0

125mg

UPTRAVI

TABS 200mcg

2

$0

UPTRAVI

TABS 400mcg

2

$0

UPTRAVI

TABS 600mcg

2

$0

UPTRAVI

TABS 800mcg

2

$0

UPTRAVI

TABS 1000mcg

2

$0

2

$0

2

$0

UPTRAVI TABS 1200mcg, 1400mcg, 1600mcg UPTRAVI TBPK

QL (90 tabs / 30 days), NM, LA, PA QL (30 tabs / 30 days), NM, LA, PA QL (30 tabs / 30 days), NM, LA, PA B/D, NM, LA QL (224 mL / 30 days), NM, PA QL (90 tabs / 30 days), NM, PA QL (120 tabs / 30 days), NM, LA, PA QL (60 tabs / 30 days), NM, LA, PA QL (480 tabs / 30 days), NM, LA, PA QL (240 tabs / 30 days), NM, LA, PA QL (150 tabs / 30 days), NM, LA, PA QL (120 tabs / 30 days), NM, LA, PA QL (90 tabs / 30 days), NM, LA, PA QL (60 tabs / 30 days), NM, LA, PA NM, LA, PA

CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS ANTIANXIETY - DRUGS TO TREAT ANXIETY alprazolam tab 0.5mg alprazolam tab 0.25mg alprazolam tab 1mg alprazolam tab 2mg buspirone hcl TABS

1 1 1 1 1

$0 $0 $0 $0 $0

QL QL QL QL

(240 (480 (120 (150

tabs tabs tabs tabs

/ / / /

30 30 30 30

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

days) days) days) days)

22

Drug Name

Drug Tier

fluvoxamine maleate TABS 25mg, 1 50mg fluvoxamine maleate TABS 100mg1 lorazepam CONC 1 lorazepam SOLN 1 lorazepam TABS 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (45 tabs / 30 days) $0 $0 $0 $0

QL (150 mL / 30 days) QL (150 tabs / 30 days)

ANTICONVULSANTS - DRUGS TO TREAT SEIZURES APTIOM 200mg APTIOM 400mg APTIOM 600mg APTIOM 800mg BANZEL SUS 40MG/ML BANZEL TAB 200MG BANZEL TAB 400MG carbamazepine CHEW; CP12; SUSP; TABS; TB12 CELONTIN clonazepam TABS 1mg clonazepam TABS 2mg clonazepam TABS .5mg clonazepam TBDP 1mg clonazepam TBDP 2mg clonazepam TBDP .5mg clonazepam TBDP .25mg clonazepam TBDP .125mg clorazepate dipotassium 3.75mg, 7.5mg clorazepate dipotassium 15mg

2 2 2 2 2 2 2 1

$0 $0 $0 $0 $0 $0 $0 $0

2 1 1 1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

1

$0

diazepam

CONC

1

$0

diazepam

SOLN

1

$0

diazepam

TABS

1

$0

DIAZEPAM GEL diazepam inj dilantin DILANTIN-125 SUS 125/5ML divalproex sodium epitol ethosuximide CAPS; SOLN felbamate SUSP

1 1 2 2 1 1 1 2

$0 $0 $0 $0 $0 $0 $0 $0

QL QL QL QL PA PA PA

(180 tabs / 30 days) (90 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days)

QL (120 tabs / 30 days) QL (300 tabs / 30 days) QL (240 tabs / 30 days) QL (120 tabs / 30 days) QL (300 tabs / 30 days) QL (240 tabs / 30 days) QL (480 tabs / 30 days) QL (960 tabs / 30 days) QL (120 tabs / 30 days), PA QL (180 tabs / 30 days), PA QL (240 mL / 30 days), PA QL (1200 mL / 30 days), PA QL (120 tabs / 30 days), PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

23

Drug Name

Drug Tier

felbamate TABS FYCOMPA 2mg

1 2

FYCOMPA

4mg

2

FYCOMPA

6mg

2

FYCOMPA

8mg, 10mg, 12mg

2

gabapentin CAPS 100mg

1

gabapentin CAPS 300mg 1 gabapentin CAPS 400mg 1 gabapentin SOLN 1 gabapentin TABS 600mg 1 gabapentin TABS 800mg 1 GABITRIL 12mg, 16mg 2 lamotrigine CHEW; TABS; TB24 1 levetiracetam SOLN; TABS; TB24 1 LEVETIRACETAM IV 2 levetiracetam oral soln 100 mg/ml 1 LYRICA CAPS 25mg, 50mg, 75mg,2 100mg, 150mg LYRICA CAPS 200mg 2 LYRICA CAPS 225mg, 300mg 2 LYRICA SOLN 2 ONFI 2 oxcarbazepine 1 PEGANONE 2 phenobarbital ELIX; TABS 2 PHENOBARBITAL SODIUM SOLN 65mg/ml phenobarbital sodium SOLN 130mg/ml phenytek phenytoin CHEW; SUSP phenytoin sodium SOLN phenytoin sodium extended POTIGA 50mg POTIGA 200mg POTIGA 300mg, 400mg primidone TABS

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 QL (180 tabs / 30 days), PA $0 QL (90 tabs / 30 days), PA $0 QL (60 tabs / 30 days), PA $0 QL (30 tabs / 30 days), PA $0 QL (1080 caps / 30 days) $0 QL (360 caps / 30 days) $0 QL (270 caps / 30 days) $0 QL (2160 mL / 30 days) $0 QL (180 tabs / 30 days) $0 QL (120 tabs / 30 days) $0 $0 $0 $0 $0 $0 QL (120 caps / 30 days) $0 $0 $0 $0 $0 $0 $0

2

$0

2

$0

2 1 1 1 2 2 2 1

$0 $0 $0 $0 $0 $0 $0 $0

QL (90 caps / 30 days) QL (60 caps / 30 days) QL (946 mL / 30 days) PA

PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older

QL (180 tabs / 30 days) QL (90 tabs / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

24

Drug Name

Drug Tier

SABRIL PACK

2

SABRIL TABS

2

SPRITAM TEGRETOL TEGRETOL-XR tiagabine hcl topiramate CPSP; TABS valproate sodium SOLN; SYRP valproic acid VIMPAT SOLN 10mg/ml VIMPAT SOLN 200mg/20ml VIMPAT TABS 50mg VIMPAT TABS 100mg, 150mg, 200mg zonisamide CAPS

2 2 2 1 1 1 1 2 2 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (180 packets / 30 days), NM, LA, PA $0 QL (180 tabs / 30 days), NM, LA, PA $0 $0 $0 $0 $0 $0 $0 $0 QL (1200 mL / 30 days) $0 $0 QL (180 tabs / 30 days) $0 QL (60 tabs / 30 days)

1

$0

ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND MEMORY LOSS donepezil hydrochloride 5mg donepezil hydrochloride 10mg, 23mg donepezil hydrochloride 5mg donepezil hydrochloride 10mg EXELON PATCHES

TABS

1

$0

TABS

1

$0

TBDP

1

$0

TBDP

1

$0

2

$0

1 1

$0 $0

QL (180 tabs / 30 days)

1

$0

QL (90 tabs / 30 days)

1

$0

1

$0

1

$0

1 2 2 2

$0 $0 $0 $0

galantamine hydrobromide SOLN galantamine hydrobromide TABS 4mg galantamine hydrobromide TABS 8mg galantamine hydrobromide TABS 12mg galantamine hydrobromide er 8mg, 16mg galantamine hydrobromide er 24mg memantine hcl NAMENDA XR NAMENDA XR TITRATION PACK NAMZARIC

QL (30 tabs / 30 days)

QL (30 tabs / 30 days)

QL (30 patches / 30 days)

QL (30 caps / 30 days)

PA; PA if < 30 yrs PA; PA if < 30 yrs PA; PA if < 30 yrs

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

25

Drug Name

rivastigmine rivastigmine mg/24hr rivastigmine mg/24hr rivastigmine mg/24hr

Drug Tier tartrate td patch 24hr 4.6

1 1

td patch 24hr 9.5

1

td patch 24hr 13.3

1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 QL (30 patches / 30 days) $0 QL (30 patches / 30 days) $0 QL (30 patches / 30 days)

ANTIDEPRESSANTS - DRUGS TO TREAT DEPRESSION amitriptyline hcl

TABS

2

$0

amoxapine tab 25mg amoxapine tab 50mg amoxapine tab 100mg amoxapine tab 150mg BRINTELLIX 5mg BRINTELLIX 10mg BRINTELLIX 20mg bupropion hcl TABS bupropion hcl TB12 bupropion hcl TB24 150mg bupropion hcl TB24 300mg citalopram hydrobromide SOLN citalopram hydrobromide TABS 10mg, 20mg citalopram hydrobromide TABS 40mg clomipramine hcl CAPS

1 1 1 1 2 2 2 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

1

$0

QL (30 tabs / 30 days)

2

$0

PA; PA if 65 years and older

desipramine hcl TABS doxepin hcl CAPS; CONC

1 2

$0 $0

duloxetine hcl CPEP 20mg, 30mg, 1 60mg EMSAM 2

$0

escitalopram oxalate SOLN escitalopram oxalate TABS 5mg, 10mg escitalopram oxalate TABS 20mg FETZIMA 20mg FETZIMA 40mg FETZIMA 80mg, 120mg FETZIMA TITRATION PACK

1 1

$0 $0

1 2 2 2 2

$0 $0 $0 $0 $0

$0

PA; PA if 65 years and older

QL (120 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days)

QL (90 tabs / 30 days) QL (30 tabs / 30 days) QL (45 tabs / 30 days)

PA; PA if 65 years and older QL (60 caps / 30 days) QL (30 patches / 30 days), PA QL (600 mL / 30 days) QL (45 tabs / 30 days) QL QL QL QL

(60 tabs / 30 days) (180 caps / 30 days) (90 caps / 30 days) (30 caps / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

26

Drug Name

Drug Tier

fluoxetine cap 10mg fluoxetine cap 20mg fluoxetine cap 40mg fluoxetine hcl SOLN fluoxetine hcl TABS 10mg fluoxetine hcl TABS 20mg imipramine hcl TABS

1 1 1 1 1 1 2

maprotiline hcl MARPLAN TAB 10MG mirtazapine TABS 7.5mg, 15mg mirtazapine TABS 30mg, 45mg mirtazapine TBDP 15mg mirtazapine TBDP 30mg, 45mg nefazodone hcl nortriptyline hcl CAPS; SOLN paroxetine hcl tabs 10mg, 20mg, 40mg paroxetine hcl tabs 30mg PAXIL SUSP phenelzine sulfate TABS PRISTIQ protriptyline hcl sertraline hcl CONC sertraline hcl TABS 25mg, 50mg sertraline hcl TABS 100mg SURMONTIL CAP 25MG

1 2 1 1 1 1 1 1 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (30 caps / 30 days) $0 QL (120 caps / 30 days) $0 $0 $0 QL (45 tabs / 30 days) $0 $0 PA; PA if 65 years and older $0 $0 QL (180 tabs / 30 days) $0 QL (45 tabs / 30 days) $0 $0 QL (30 tabs / 30 days) $0 $0 $0 $0 QL (45 tabs / 30 days)

1 2 1 2 1 1 1 1 2

$0 $0 $0 $0 $0 $0 $0 $0 $0

SURMONTIL CAP 50MG

2

$0

SURMONTIL CAP 100MG

2

$0

tranylcypromine sulfate 1 trazodone hcl TABS 50mg, 1 100mg, 150mg trimipramine maleate CAPS 25mg 2

$0 $0 $0

QL (60 tabs / 30 days) QL (900 mL / 30 days) QL (30 tabs / 30 days)

QL (45 tabs / 30 days) QL (240 caps / 30 days), PA; PA if 65 years and older QL (120 caps / 30 days), PA; PA if 65 years and older QL (60 caps / 30 days), PA; PA if 65 years and older

QL (240 caps / 30 days), PA; PA if 65 years and older

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

27

Drug Name

Drug Tier

trimipramine maleate CAPS 100mg

2

venlafaxine hcl CP24 37.5mg, 75mg venlafaxine hcl CP24 150mg venlafaxine hcl TABS VIIBRYD KIT VIIBRYD TABS VIIBRYD STARTER PACK

1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (120 caps / 30 days), PA; PA if 65 years and older $0 QL (60 caps / 30 days), PA; PA if 65 years and older $0 QL (30 caps / 30 days)

1 1 2 2 2

$0 $0 $0 $0 $0

trimipramine maleate CAPS 50mg 2

QL (60 caps / 30 days)

QL (30 tabs / 30 days)

ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT PARKINSONS DISEASE amantadine hcl CAPS; SYRP; TABS APOKYN AZILECT BENZTROPINE MESYLATE SOLN benztropine mesylate TABS

1

$0

2 2 1 2

$0 $0 $0 $0

bromocriptine mesylate CAPS; 1 TABS carbidopa-levodopa 1 CARBIDOPA/LEVODOPA/ENTACAPO 1 NE ENTACAPONE 1 NEUPRO 2 pramipexole dihydrochloride TABS1 ropinirole hydrochloride TABS 1 selegiline hcl CAPS; TABS 1 trihexyphenidyl hcl 2

$0

NM, LA, PA

PA; PA if 65 years and older

$0 $0 $0 $0 $0 $0 $0 $0

PA; PA if 65 years and older

ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES ABILIFY DISCMELT TAB 10MG ABILIFY MAINTENA

2 2

$0 $0

aripiprazole odt 2 aripiprazole oral solution 1 mg/ml 2 aripiprazole tabs 2 chlorpromazine hcl TABS 1 chlorpromazine inj 2

$0 $0 $0 $0 $0

QL (60 tabs / 30 days) QL (1 injection / 28 days) QL (60 tabs / 30 days) QL (900ml / 30 days) QL (30 tabs / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

28

Drug Name

Drug Tier

clozapine TABS 25mg, 50mg clozapine TABS 100mg clozapine TABS 200mg CLOZAPINE TBDP 12.5mg, 25mg CLOZAPINE TBDP 100mg

1 1 1 1 1

CLOZAPINE TBDP 150mg

2

CLOZAPINE TBDP 200mg

2

FANAPT

2

FANAPT TITRATION PACK FAZACLO TAB 150MG

2 2

FAZACLO TAB 200MG

2

fluphenazine decanoate SOLN fluphenazine hcl GEODON SOLR haloperidol TABS haloperidol decanoate SOLN haloperidol lactate inj 5 mg/ml haloperidol lactate oral conc 2 mg/ml INVEGA 1.5mg, 3mg, 9mg INVEGA 6mg INVEGA SUST INJ 39 MG/0.25 ML

1 1 2 1 1 1 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 QL (270 tabs / 30 days) $0 QL (135 tabs / 30 days) $0 PA $0 QL (270 tabs / 30 days), PA $0 QL (180 tabs / 30 days), PA $0 QL (135 tabs / 30 days), PA $0 QL (60 tabs / 30 days), ST $0 ST $0 QL (180 tabs / 30 days), PA $0 QL (135 tabs / 30 days), PA $0 $0 $0 QL (6 mL / 3 days) $0 $0 $0 $0

2 2 2

$0 $0 $0

INVEGA SUST INJ 78 MG/0.5 ML

2

$0

INVEGA SUST INJ 117 MG/0.75 ML 2

$0

INVEGA SUST INJ 156MG/ML

2

$0

INVEGA SUST INJ 234 MG/1.5 ML 2

$0

INVEGA TRINZA LATUDA 20mg LATUDA 40mg, 120mg LATUDA 60mg, 80mg loxapine succinate molindone hcl

$0 $0 $0 $0 $0 $0

2 2 2 2 1 1

QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (1 injection / 28 days) QL (1 injection / 28 days) QL (1 injection / 28 days) QL (1 injection / 28 days) QL (1 injection / 28 days) QL (1 syringe / 90 days) QL (240 tabs / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

29

Drug Name

Drug Tier

olanzapine SOLR olanzapine TABS 2.5mg, 5mg, 7.5mg olanzapine TABS 10mg, 15mg, 20mg olanzapine TBDP 5mg olanzapine TBDP 10mg, 15mg, 20mg paliperidone 1.5mg, 3mg, 9mg paliperidone 6mg perphenazine TABS pimozide quetiapine fumarate REXULTI 1mg

1 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (3 vials / 1 day) $0 QL (30 tabs / 30 days)

1

$0

QL (60 tabs / 30 days)

1 1

$0 $0

QL (30 tabs / 30 days) QL (60 tabs / 30 days)

1 1 1 1 1 2

$0 $0 $0 $0 $0 $0

QL (30 tabs / 30 days) QL (60 tabs / 30 days)

REXULTI

2mg

2

$0

REXULTI

3mg, 4mg

2

$0

REXULTI

.5mg

2

$0

REXULTI

.25mg

2

$0

RISPERDAL INJ 12.5MG

2

$0

RISPERDAL INJ 25MG

2

$0

RISPERDAL INJ 37.5MG

2

$0

RISPERDAL INJ 50MG

2

$0

risperidone SOLN 1 risperidone TABS 1mg, 2mg, 3mg 1 risperidone TABS 4mg 1 risperidone TABS .25mg, .5mg 1 risperidone TBDP 1mg, 2mg, 3mg 1 risperidone TBDP 4mg 1 risperidone TBDP .25mg, .5mg 1 SAPHRIS 2.5mg 2 SAPHRIS 5mg 2 SAPHRIS 10mg 2 SEROQUEL XR 50mg 2 SEROQUEL XR 150mg, 200mg 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

QL (90 tabs / 30 days) QL (90 tabs / 30 days), ST QL (60 tabs / 30 days), ST QL (30 tabs / 30 days), ST QL (180 tabs / 30 days), ST QL (360 tabs / 30 days), ST QL (2 injections / 28 days) QL (2 injections / 28 days) QL (2 injections / 28 days) QL (2 injections / 28 days) QL (240 mL / 30 days) QL (60 tabs / 30 days) QL (120 tabs / 30 days) QL (90 tabs / 30 days) QL (60 tabs / 30 days) QL (120 tabs / 30 days) QL (90 tabs / 30 days) QL (240 tabs / 30 days) QL (120 tabs / 30 days) QL (60 tabs / 30 days) QL (120 tabs / 30 days) QL (30 tabs / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

30

Drug Name

Drug Tier

SEROQUEL XR 300mg, 400mg thioridazine hcl TABS

2 2

thiothixene trifluoperazine hcl VERSACLOZ

1 1 2

VRAYLAR CAPS 1.5mg

2

VRAYLAR CAPS 3mg

2

VRAYLAR CAPS 4.5mg, 6mg

2

VRAYLAR CPPK ziprasidone hcl 20mg, 40mg ziprasidone hcl 60mg, 80mg ZYPREXA RELPREVV 300mg

2 1 1 2

ZYPREXA RELPREVV 405mg ZYPREXA RELPREVV INJ 210MG

2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (60 tabs / 30 days) $0 PA; PA if 65 years and older $0 $0 $0 QL (600 mL / 30 days), PA $0 QL (120 caps / 30 days), ST $0 QL (60 caps / 30 days), ST $0 QL (30 caps / 30 days), ST $0 ST $0 QL (60 caps / 30 days) $0 QL (90 caps / 30 days) $0 QL (2 vials / 28 days), PA $0 QL (1 vial / 28 days), PA $0 QL (2 vials / 28 days), PA

ATTENTION DEFICIT HYPERACTIVITY DISORDER - DRUGS TO TREAT ADHD amphetamine-dextroamphetamine cap sr 24hr 5 mg amphetamine-dextroamphetamine cap sr 24hr 10 mg amphetamine-dextroamphetamine cap sr 24hr 15 mg amphetamine-dextroamphetamine cap sr 24hr 20 mg amphetamine-dextroamphetamine cap sr 24hr 25 mg amphetamine-dextroamphetamine cap sr 24hr 30 mg amphetamine-dextroamphetamine tab 5 mg amphetamine-dextroamphetamine tab 7.5 mg amphetamine-dextroamphetamine tab 10 mg amphetamine-dextroamphetamine tab 12.5 mg

1

$0

QL (90 caps / 30 days)

1

$0

QL (90 caps / 30 days)

1

$0

QL (30 caps / 30 days)

1

$0

QL (30 caps / 30 days)

1

$0

QL (30 caps / 30 days)

1

$0

QL (30 caps / 30 days)

1

$0

QL (360 tabs / 30 days)

1

$0

QL (240 tabs / 30 days)

1

$0

QL (180 tabs / 30 days)

1

$0

QL (144 tabs / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

31

Drug Name

Drug Tier

amphetamine-dextroamphetamine tab 15 mg amphetamine-dextroamphetamine tab 20 mg amphetamine-dextroamphetamine tab 30 mg guanfacine er (adhd)

1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (120 tabs / 30 days)

1

$0

QL (90 tabs / 30 days)

1

$0

QL (60 tabs / 30 days)

2

$0

metadate er tab 20mg methylphenidate hcl TABS 5mg, 10mg methylphenidate hcl TABS 20mg methylphenidate hcl TBCR methylphenidate hcl oral soln 5mg/5ml methylphenidate hcl oral soln 10mg/5ml STRATTERA 10mg, 18mg, 25mg STRATTERA 40mg STRATTERA 60mg, 80mg, 100mg

1 1

$0 $0

PA; PA if 65 years and older QL (90 tabs / 30 days) QL (180 tabs / 30 days)

1 1 1

$0 $0 $0

QL (90 tabs / 30 days) QL (90 tabs / 30 days) QL (1800 mL / 30 days)

1

$0

QL (900 mL / 30 days)

2 2 2

$0 $0 $0

QL (120 caps / 30 days) QL (60 caps / 30 days) QL (30 caps / 30 days)

HYPNOTICS - DRUGS TO TREAT INSOMNIA HETLIOZ ROZEREM SILENOR 3mg SILENOR 6mg temazepam 7.5mg

2 2 2 2 1

$0 $0 $0 $0 $0

temazepam

1

$0

2

$0

15mg

zolpidem tartrate

TABS

NM, LA, PA QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days) QL (30 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year QL (60 caps / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year QL (30 tabs / 30 days), PA; PA applies if 65 years and older after a 90 day supply in a calendar year

MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES dihydroergotamine mesylate 1mg/ml naratriptan hcl

1

$0

1

$0

QL (9 tabs / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

32

Drug Name

Drug Tier

RELPAX rizatriptan benzoate SUMATRIPTAN SOLN 5mg/act

2 1 1

SUMATRIPTAN

1

SOLN 20mg/act

SUMATRIPTAN INJ 4MG/0.5ML

1

sumatriptan inj 6mg/0.5ml SOAJ; 1 SOLN; SOSY SUMATRIPTAN INJ 6MG/0.5ML 1 SOCT sumatriptan succinate TABS 1 zolmitriptan TABS 1 zolmitriptan odt 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (12 tabs / 30 days) $0 QL (18 tabs / 30 days) $0 QL (24 inhalers / 30 days) $0 QL (12 inhalers / 30 days) $0 QL (12 injections / 30 days) $0 QL (12 injections / 30 days) $0 QL (12 injections / 30 days) $0 QL (9 tabs / 30 days) $0 QL (12 tabs / 30 days) $0 QL (12 tabs / 30 days)

MISCELLANEOUS lithium carbonate CAPS; TABS lithium carbonate er LITHIUM SOLN 8MEQ/5ML NUEDEXTA pyridostigmine bromide TABS riluzole tetrabenazine 12.5mg

1 1 2 2 1 1 2

$0 $0 $0 $0 $0 $0 $0

tetrabenazine

2

$0

25mg

PA

QL (240 tabs / 30 days), NM, PA QL (120 tabs / 30 days), NM, PA

MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT MULTIPLE SCLEROSIS AMPYRA BETASERON

2 2

$0 $0

COPAXONE INJ 40MG/ML

2

$0

GILENYA CAP 0.5MG

2

$0

glatopa

2

$0

TYSABRI

2

$0

NM, LA, PA QL (14 syringes / 28 days), NM, PA QL (12 syringes / 28 days), NM, PA QL (28 caps / 28 days), NM, PA QL (30 syringes / 30 days), NM, PA NM, LA, PA

MUSCULOSKELETAL THERAPY AGENTS - DRUGS TO TREAT MUSCLE SPASMS baclofen TABS dantrolene sodium

CAPS

1 1

$0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

33

Drug Name

tizanidine hcl

Drug Tier TABS

1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0

NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP DISORDERS NUVIGIL 50mg

2

$0

QL (150 tabs / 30 days), PA QL (60 tabs / 30 days), PA QL (30 tabs / 30 days), PA QL (540 mL / 30 days), LA, PA

NUVIGIL 150mg

2

$0

NUVIGIL 200mg, 250mg

2

$0

XYREM

2

$0

acamprosate calcium 1 buprenorphine hcl SUBL 1 buprenorphine hcl-naloxone hcl sl 1

$0 $0 $0

buproban bupropion hcl (smoking deterrent) CHANTIX CHANTIX CONTINUING MONTH CHANTIX STARTER PACK diphenhydramine hcl (sleep) diphenhydramine-acetaminophen (sleep) disulfiram TABS doxylamine succinate (sleep) ibuprofen-diphenhydramine citrate naloxone hcl SOLN naltrexone hcl TABS nicotine nicotine polacrilex GUM nicotine polacrilex LOZG 2mg, 4mg NICOTINE POLACRILEX LOZG 2mg, 4mg NICOTINE TRANSDERMAL SYST NICOTROL INHALER NICOTROL NS SUBOXONE MIS 2-0.5MG

1 1 2 2 2 3 3

$0 $0 $0 $0 $0 $0 $0

1 3 3 1 1 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0

3

$0

NM; *

3 2 2 2

$0 $0 $0 $0

NM; *

SUBOXONE MIS 4-1MG

2

$0

SUBOXONE MIS 8-2MG

2

$0

PSYCHOTHERAPEUTIC-MISC PA QL (120 tabs / 30 days), PA

PA PA PA NM; * NM; *

NM; * NM; *

NM; * NM; * NM; *

QL (120 SL films / 30 days), PA QL (120 SL films / 30 days), PA QL (120 SL films / 30 days), PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

34

Drug Name

Drug Tier

SUBOXONE MIS 12-3MG

2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (60 SL films / 30 days), PA

ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE HORMONES ANDROGENS - DRUGS TO REGULATE MALE HORMONES ANDRODERM

2

$0

AXIRON

2

$0

1 2 1 1

$0 $0 $0 $0

oxandrolone oxandrolone testosterone testosterone

TABS 2.5mg TABS 10mg cypionate SOLN enanthate SOLN

QL (30 patches / 30 days), PA QL (440 mL / 30 days), PA PA PA PA PA

ANTIDIABETICS, INJECTABLE - DRUGS TO TREAT DIABETES ALCOHOL SWABS BYDUREON PEN BYDUREON SRER BYETTA GAUZE PADS 2" X 2" HUMULIN R U-500 VIAL (CONCENTRATE) INSULIN PEN NEEDLE INSULIN SAFETY NEEDLES INSULIN SYRINGE LANTUS LANTUS SOLOSTAR LEVEMIR LEVEMIR FLEXTOUCH NOVOLIN 70/30

2 2 2 2 2 2

$0 $0 $0 $0 $0 $0

2 2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0

NOVOLIN N

2

$0

NOVOLIN R

2

$0

NOVOLOG NOVOLOG FLEXPEN NOVOLOG MIX 70/30 NOVOLOG MIX 70/30 PREFILL NOVOLOG PENFILL SYMLINPEN 60

2 2 2 2 2 2

$0 $0 $0 $0 $0 $0

QL (4 pens / 28 days) QL (4 vials / 28 days) QL (1 pen / 30 days) B/D

(brand RELION not covered) (brand RELION not covered) (brand RELION not covered)

QL (8 pens / 30 days), PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

35

Drug Name

Drug Tier

SYMLINPEN 120

2

TOUJEO SOLOSTAR TRESIBA FLEXTOUCH TRULICITY VICTOZA

2 2 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (4 pens / 30 days), PA $0 $0 $0 QL (4 pens / 28 days) $0 QL (3 pens / 30 days)

ANTIDIABETICS, ORAL - DRUGS TO TREAT DIABETES acarbose 1 FARXIGA 5mg 2 FARXIGA 10mg 2 glimepiride 1mg 1 glimepiride 2mg 1 glimepiride 4mg 1 glip/metform tab 5-500mg 1 glipizide TABS 5mg 1 glipizide TABS 10mg 1 glipizide TB24 2.5mg 1 glipizide TB24 5mg 1 glipizide TB24 10mg 1 GLIPIZIDE XL TB24 2.5MG 1 GLIPIZIDE XL TB24 5MG 1 glipizide-metformin hcl tab 2.5-250 1 mg glipizide-metformin hcl tab 2.5-500 1 mg INVOKAMET TAB 50-500MG 2 INVOKAMET TAB 50-1000 2 INVOKAMET TAB 150-500 2 INVOKAMET TAB 150-1000 2 INVOKANA 100mg 2 INVOKANA 300mg 2 JANUMET 2 JANUMET XR TAB 50-500MG 2 JANUMET XR TAB 50-1000 2 JANUMET XR TAB 100-1000 2 JANUVIA 2 JENTADUETO 2 metformin er 500mg 1 metformin er 750mg 1 metformin hcl TABS 500mg 1 metformin hcl TABS 850mg 1 metformin hcl TABS 1000mg 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

QL QL QL QL QL QL QL QL QL QL QL QL QL QL

$0

QL (120 tabs / 30 days)

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL QL

(60 tabs / 30 days) (30 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (120 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (240 tabs / 30 days) (120 tabs / 30 days) (240 tabs / 30 days)

(120 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (90 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (60 tabs / 30 days) (30 tabs / 30 days) (30 tabs / 30 days) (60 tabs / 30 days) (120 tabs / 30 days) (60 tabs / 30 days) (150 tabs / 30 days) (90 tabs / 30 days) (75 tabs / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

36

Drug Name

nateglinide pioglitazone hcl repaglinide 2mg repaglinide .5mg, 1mg TRADJENTA XIGDUO XR TAB 5-500MG XIGDUO XR TAB 5-1000MG XIGDUO XR TAB 10-500MG XIGDUO XR TAB 10-1000MG

Drug Tier 1 1 1 1 2 2 2 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (90 tabs / 30 days) $0 QL (30 tabs / 30 days) $0 QL (240 tabs / 30 days) $0 QL (120 tabs / 30 days) $0 QL (30 tabs / 30 days) $0 QL (60 tabs / 30 days) $0 QL (60 tabs / 30 days) $0 QL (30 tabs / 30 days) $0 QL (30 tabs / 30 days)

BISPHOSPHONATES - DRUGS TO TREAT alendronate sodium TABS 5mg, 1 10mg, 40mg alendronate sodium TABS 35mg, 1 70mg ibandronate tab 150mg 1

$0

pamidronate disodium SOLN 1 zoledronic acid SOLN 5mg/100ml 1 zoledronic inj 4mg/5ml 1

$0 $0 $0

BONE LOSS

$0

QL (4 tabs / 28 days)

$0

B/D, QL (1 tab / 30 days) B/D B/D, NM B/D, NM

CALCIUM RECEPTOR AGONISTS SENSIPAR 30mg, 90mg

2

$0

SENSIPAR 60mg

2

$0

2 2 2 2 1 1 1 2

$0 $0 $0 $0 $0 $0 $0 $0

QL (120 tabs / 30 days), NM QL (60 tabs / 30 days), NM

CHELATING AGENTS CHEMET DEPEN TITRATABS EXJADE FERRIPROX kionex sodium polystyrene sulfonate sps susp 15gm/60ml SYPRINE

NM, LA, PA NM, LA, PA

CONTRACEPTIVES - DRUGS FOR BIRTH CONTROL altavera apri 28 day aranelle 28 aubra 28 day aviane 28 balziva 28 day bekyree 28 day blisovi 21 fe 1.5/30 28 day pack

1 1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

37

Drug Name

blisovi 21 fe 1/20 28 day pack briellyn 28 day camila 28 day cryselle 28 cyclafem 1/35 28 day cyclafem 7/7/7 28 day cyred tab deblitane 28 day delyla 28 day desogestrel-ethinyl estradiol (biphasic) drospirenone-ethinyl estradiol ELLA emoquette enpresse 28 day errin 28 day estarylla tab 0.25-35 falmina 28 day GIANVI gildagia gildess 1.5/30 21 day heather introvale 91 day JOLESSA TAB 0.15-0.03 MG JOLIVETTE juleber 28 day junel 1.5/30 21 day junel 1/20 21 day junel fe 1.5/30 28 day junel fe 1/20 28 day kariva 28 day kelnor 1/35 28 day kimidess 28 day larin 1.5/30 larin 1/20 larin fe 1.5/30 larin fe 1/20 LEENA lessina 28 day levonest 28 day levonor/ethi tab levonorgestrel & eth estradiol

Drug Tier 1 1 1 1 1 1 1 1 1 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

38

Drug Name

levonorgestrel (emergency oc) 1.5mg levonorgestrel (emergency oc) .75mg, 1.5mg levonorgestrel-ethinyl estradiol (91-day) levora 0.15/30 28 day loryna 28 day low-ogestrel lutera 28 day lyza marlissa 28 day medroxyprogesterone acetate 150 mg/ml MICROGESTIN 1.5/30 MICROGESTIN 1/20 MICROGESTIN FE 1.5/30 MICROGESTIN FE 1/20 mono-linyah tab 0.25-35 MONONESSA myzilra necon 0.5/35 28 day necon 1/35 28 day NECON 7/7/7 necon 10/11 28 day NECON TAB 1/50-28 nikki 28 day NORA-BE TAB norethindrone (contraceptive) norgest/ethi tab 0.25/35 norgestimate-ethinyl estradiol (triphasic) norlyroc 28 day nortrel 0.5/35 28 day nortrel 1/35 21 day nortrel 1/35 28 day nortrel 7/7/7 28 day NUVARING OCELLA TAB 3-0.03MG orsythia 28 day philith pimtrea pack

Drug Tier 3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; *

1

$0

1

$0

1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0

1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

1 1 1 1 1 2 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

39

Drug Name

pirmella 1/35 28 day portia 28 day previfem 28 day quasense 91 day reclipsen 28 day setlakin tab sharobel 28 day sprintec 28 day sronyx syeda tarina fe 1/20 28 day tri-legest 28 day tri-previfem 28 day tri-sprintec 28 day TRINESSA trivora 28 day velivet 28 day vestura vienva 28 day viorele vyfemla 28 day xulane zarah zenchent 28 day zovia 1/35e 28 day zovia 1/50e 28 day

Drug Tier 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

1 2

$0 $0

ENDOMETRIOSIS danazol CAPS SYNAREL

ENZYME REPLACEMENTS - DRUGS TO TREAT ENZYME DEFICIENCIES ADAGEN 2 ALDURAZYME 2 CARBAGLU 2 CERDELGA 2 CEREZYME 2 CYSTADANE 2 CYSTAGON 2 FABRAZYME 2 KUVAN 2 levocarnitine (metabolic modifiers) 1 LUMIZYME 2 MYOZYME 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM, NM, NM, NM, NM, NM, NM, NM, NM, B/D NM, NM,

LA, LA, LA, PA LA, LA LA, LA, LA,

PA PA PA PA PA PA PA

LA, PA LA, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

40

Drug Name

NAGLAZYME ORFADIN RAVICTI sodium phenylbutyrate ZAVESCA

Drug Tier 2 2 2 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM, LA, PA $0 NM, LA, PA $0 NM, PA $0 NM $0 NM, LA, PA

ESTROGENS - DRUGS TO REGULATE FEMALE HORMONES DELESTROGEN 10mg/ml estrace CREA estradiol PTWK

2 2 2

$0 $0 $0

estradiol TABS

2

$0

estradiol valerate OIL fyavolv tab 1 mg-5 mcg

1 2

$0 $0

jinteli

2

$0

norethindrone acetate-ethinyl estradiol VAGIFEM

2

$0

2

$0

PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older PA; PA if 65 years and older

GLUCOCORTICOIDS - DRUGS TO TREAT INFLAMMATORY RESPONSE a-hydrocort cortisone acetate TABS dexamethasone CONC; ELIX; SOLN; TABS dexamethasone sodium phosphate fludrocortisone acetate TABS hydrocortisone TABS methylpr ace inj 40mg/ml methylpr ace inj 80mg/ml methylpr ss inj 1gm methylpr ss inj 40mg methylpr ss inj 125mg methylpred pak 4mg methylpred tab 4mg methylpred tab 8mg methylpred tab 16mg methylpred tab 32mg pred sod pho sol 5mg/5ml prednisolone sol 15mg/5ml prednisolone sol 25mg/5ml prednisolone syp 15mg/5ml

1 1 1

$0 $0 $0

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

41

Drug Name

prednisone con 5mg/ml prednisone pak 5mg prednisone pak 10mg prednisone sol 5mg/5ml prednisone tab 1mg prednisone tab 2.5mg prednisone tab 5mg prednisone tab 10mg prednisone tab 20mg prednisone tab 50mg SOLU-CORTEF 250mg

Drug Tier 2 1 1 1 1 1 1 1 1 1 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 B/D $0 $0 $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0

GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT LOW BLOOD SUGAR GLUCAGEN HYPOKIT GLUCAGON EMERGENCY KIT KORLYM PROGLYCEM SUS 50MG/ML

2 2 2 2

$0 $0 $0 $0

NM, LA, PA

HUMAN GROWTH HORMONES - DRUGS TO REGULATE PITUITARY HORMONES NORDITROPIN FLEXPRO

2

$0

NM, PA

cabergoline calcitonin (salmon) FORTICAL INCRELEX methylergonovine maleate TABS MIACALCIN 200unit/ml octreotide acetate 50mcg/ml, 100mcg/ml octreotide acetate 200mcg/ml, 500mcg/ml, 1000mcg/ml PROLIA

1 1 2 2 1 2 1

$0 $0 $0 $0 $0 $0 $0

NM, LA, PA

2

$0

NM, PA

2

$0

QL (1 syringe / 180 days), NM

raloxifene hcl SANDOSTATIN LAR DEPOT SIGNIFOR SOMATULINE DEPOT SOMAVERT XGEVA

1 2 2 2 2 2

$0 $0 $0 $0 $0 $0

MISCELLANEOUS

B/D NM, PA

NM, NM, NM, NM, NM,

PA LA, PA PA LA, PA PA

PARATHYROID HORMONES - DRUGS TO REGULATE PARATHYROID LEVELS FORTEO

2

$0

QL (1 pen / 28 days), NM, PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

42

Drug Name

NATPARA

Drug Tier 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM, PA

PHOSPHATE BINDER AGENTS - DRUGS TO REGULATE CALCIUM AND PHOSPHORUS LEVELS calcium acetate (phosphate binder) 1 RENVELA PAK 0.8GM 2 RENVELA PAK 2.4GM 2 RENVELA TAB 800MG 2

$0 $0 $0 $0

PROGESTINS - DRUGS TO REGULATE FEMALE HORMONES medroxyprogesterone acetate tab 1 norethindrone acetate TABS 1

$0 $0

THYROID AGENTS - DRUGS TO REGULATE levothyroxine sodium TABS LEVOXYL liothyronine sodium TABS methimazole TABS propylthiouracil TABS SYNTHROID UNITHROID

1 1 1 1 1 2 1

THYROID LEVELS

$0 $0 $0 $0 $0 $0 $0

VASOPRESSINS - DRUGS TO REGULATE PITUITARY HORMONES desmopressin acetate spray desmopressin acetate spray refrigerated desmopressin acetate tabs desmopressin inj 4mcg/ml DESMOPRESSIN SOL 0.01%

1 1

$0 $0

1 1 1

$0 $0 $0

GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS ANTACIDS alum & mag hydrox-simethicone ALUMINUM HYDROXIDE aluminum hydroxide-mag carb aluminum hydroxide-mag trisil calcium carbonate (antacid) calcium carbonate-mag hydrox calcium carbonate-simethicone GAVISCON CHEW GAVISCON EXTRA STRENGTH R MAG-AL MAGNESIUM OXIDE CAPS magnesium oxide TABS 250mg, 400mg, 420mg

3 3 3 3 3 3 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * * * *

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

43

Drug Name

Drug Tier

SODIUM BICARBONATE

POWD

3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; *

ANTI-DIARRHEAL bismuth subsalicylate CHEW; 3 SUSP; TABS FLORASTOR KIDS 3 lactobacillus 3 lactobacillus rhamnosus (gg) 3 loperamide hcl LIQD; SUSP; TABS 3 RA PROBIOTIC COMPLEX CAPS 3 RISA-BID PROBIOTIC 3

$0

NM; *

$0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM;

* * * * * *

ANTIEMETICS - DRUGS FOR NAUSEA AND VOMITING compro dimenhydrinate TABS dronabinol 2.5mg, 5mg

1 3 1

$0 $0 $0

dronabinol

2

$0

EMEND CAP 40MG 2 EMEND CAP 80MG 2 EMEND CAP 125MG 2 EMEND PAK 80 & 125 2 granisetron hcl SOLN 1 granisetron hcl TABS 1 meclizine hcl CHEW 3 meclizine hcl TABS 12.5mg, 25mg 1 meclizine hcl TABS 25mg 3 metoclopramide hcl SOLN; TABS 1 metoclopramide inj 1 ondansetron hcl TABS 1 ondansetron hcl inj 1 ondansetron hcl oral soln 1 ondansetron odt 1 phenadoz 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

phenergan SUPP

2

$0

prochlorperazine inj prochlorperazine maleate TABS prochlorperazine supp promethazine hcl SOLN; SUPP; SYRP; TABS

1 1 1 2

$0 $0 $0 $0

10mg

NM; * B/D, QL (60 caps / 30 days) B/D, QL (60 caps / 30 days) B/D B/D B/D B/D B/D NM; * NM; *

B/D B/D B/D PA; PA if 65 years and older PA; PA if 65 years and older

PA; PA if 65 years and older

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

44

Drug Name

Drug Tier

promethegan

2

TRANSDERM-SCOP

2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 PA; PA if 65 years and older $0 QL (10 patches / 30 days), PA; PA if 65 years and older

ANTISPASMODICS - DRUGS FOR STOMACH SPASMS CUVPOSA 2 dicyclomine hcl CAPS 1 dicyclomine hcl SOLN 10mg/5ml 1 dicyclomine hcl TABS 1 glycopyrrolate TABS 1 glycopyrrolate inj 1

$0 $0 $0 $0 $0 $0

H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS AND STOMACH ACID AXID AR famotidine SUSR famotidine TABS 10mg, 20mg famotidine TABS 20mg, 40mg famotidine inj PEPCID AC CHEW ranitidine hcl SOLN ranitidine hcl TABS 75mg, 150mg ranitidine hcl TABS 150mg, 300mg ranitidine hcl inj ranitidine syrup

3 1 3 1 1 3 1 3 1

$0 $0 $0 $0 $0 $0 $0 $0 $0

1 1

$0 $0

NM; * NM; *

NM; * NM; *

INFLAMMATORY BOWEL DISEASE APRISO 2 ASACOL HD 2 balsalazide disodium 1 budesonide ec 2 CANASA 2 colocort enema 100mg 1 DELZICOL 2 DIPENTUM 2 HYDROCORTISONE (INTRARECTAL)1 mesalamine enema 1 mesalamine w/ cleanser 1 sulfasalazine TABS 1 sulfasalazine ec 1 UCERIS TB24 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

LAXATIVES PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

45

Drug Name

benzocaine-docusate sodium bisacodyl SUPP; TBEC calcium polycarbophil constulose corn dextrin docusate calcium docusate sodium CAPS 50mg, 100mg docusate sodium ENEM docusate sodium LIQD docusate sodium SYRP docusate sodium TABS enulose EQUALACTIN FIBER CHEW fiber POWD FLEET BISACODYL gaviltye-g gavilyte-c gavilyte-h gavilyte-n generlac GOLYTELY HYDROCIL INSTANT PACK KONSYL PACK 28.3%, 100% KONSYL POWD 60.3%, 71.67% KONSYL-D lactulose lactulose (encephalopathy) magnesium citrate SOLN magnesium hydroxide SUSP magnesium oxide (laxative) magnesium sulfate (laxative) METAMUCIL WAFR METAMUCIL MULTIHEALTH FIB POWD 63% METAMUCIL SMOOTH TEXTURE methylcellulose (laxative) MILK OF MAGNESIA CONCENTR mineral oil ENEM MINERAL OIL OIL MOVIPREP

Drug Tier 3 3 3 1 3 3 3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; * $0 NM; * $0 NM; * $0 $0 NM; * $0 NM; * $0 NM; *

3 3 3 3 1 3 3 3 3 1 1 1 1 1 2 3 3 3 3 1 1 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM;

* * * *

NM; NM; NM; NM;

* * * *

NM; NM; NM; NM;

* * * *

NM; NM; NM; NM; NM; NM;

* * * * * *

3 3 3 3 3 2

$0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM;

* * * * *

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

46

Drug Name

NULYTELY/FLAVOR PACKS NUTRISOURCE FIBER PEDIA-LAX LIQD PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE peg 3350-potassium chloride-sod bicarbonate-sod chloride PEG 3350/ELECTROLYTES polyethylene glycol 3350 PACK; POWD psyllium RELISTOR SENNA SYRP SENNA PROMPT sennosides sennosides-docusate sodium sodium phosphates SUPREP BOWEL PREP trilyte wheat dextrin-calcium

Drug Tier 2 3 3 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 NM; * $0 NM; * $0

1

$0

1 1

$0 $0

3 2 3 3 3 3 3 2 1 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; PA NM; NM; NM; NM; NM;

2 2 2 2 1 2 2 2 1 1 2 2 2 1 1 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

PA QL (60 caps / 30 days) QL (60 caps / 30 days)

2 2

$0 $0

* * * * * *

NM; *

MISCELLANEOUS alosetron hcl AMITIZA CAP 8MCG AMITIZA CAP 24MCG cromolyn sodium (mastocytosis) diphenoxylate w/ atropine GATTEX LINZESS 145mcg LINZESS 290mcg loperamide hcl CAPS misoprostol TABS MOVANTIK 12.5mg MOVANTIK 25mg SUCRAID sucralfate TABS ursodiol CAPS; TABS XIFAXAN 550mg

NM, LA, PA QL (60 caps / 30 days) QL (30 caps / 30 days)

QL (60 tabs / 30 days) QL (30 tabs / 30 days) LA

PA

PANCREATIC ENZYMES CREON ZENPEP

PROTON PUMP INHIBITORS - DRUGS FOR ULCERS AND STOMACH ACID PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

47

Drug Name

Drug Tier

DEXILANT esomeprazole magnesium esomeprazole sodium inj famotidine-calcium carbonate-magnesium hydroxide lansoprazole CPDR 15mg NEXIUM CAP 20MG NEXIUM CAP 40MG NEXIUM GRA 2.5MG DR NEXIUM GRA 5MG DR NEXIUM GRA 10MG DR

2 1 1 3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (30 caps / 30 days) $0 QL (30 caps / 30 days) $0 $0 NM; *

3 2 2 2 2 2

$0 $0 $0 $0 $0 $0

NEXIUM GRA 20MG DR

2

$0

NEXIUM GRA 40MG DR

2

$0

omeprazole CPDR 10mg, 40mg omeprazole CPDR 20mg OMEPRAZOLE TBEC omeprazole-sodium bicarbonate pantoprazole sodium tbec PRILOSEC OTC

1 1 3 3 1 3

$0 $0 $0 $0 $0 $0

NM; * QL (30 caps / 30 days) QL (30 caps / 30 days)

QL (30 days) QL (30 days) QL (30 days) QL (30 QL (60 NM; * NM; * QL (30 NM; *

packets / 30 packets / 30 packets / 30 caps / 30 days) caps / 30 days)

tabs / 30 days)

GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS BENIGN PROSTATIC HYPERPLASIA - DRUGS TO TREAT ENLARGED PROSTATE alfuzosin hcl dutasteride dutasteride-tamsulosin hcl finasteride TABS 5mg tamsulosin hcl

1 1 1 1 1

$0 $0 $0 $0 $0

bethanechol chloride TABS 1 ELMIRON 2 POTASSIUM CITRATE 1 (ALKALINIZER) 540mg, 1080mg

$0 $0 $0

QL (30 tabs / 30 days) QL (30 caps / 30 days) QL (30 caps / 30 days)

MISCELLANEOUS

URINARY ANTISPASMODICS - DRUGS TO TREAT URINARY INCONTINENCE MYRBETRIQ 25mg MYRBETRIQ 50mg oxybutynin chloride oxybutynin chloride

SYRP TABS

2 2 1 1

$0 $0 $0 $0

QL (60 tabs / 30 days) QL (30 tabs / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

48

Drug Name

oxybutynin chloride TB24 5mg oxybutynin chloride TB24 10mg, 15mg tolterodine tartrate cap er tolterodine tartrate tabs TOVIAZ trospium chloride TABS VESICARE

Drug Tier 1 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (30 tabs / 30 days) $0 QL (60 tabs / 30 days)

1 1 2 1 2

$0 $0 $0 $0 $0

1 3 1 3 3 3

$0 $0 $0 $0 $0 $0

3 1 3 1 1 1

$0 $0 $0 $0 $0 $0

QL (30 caps / 30 days) QL (30 tabs / 30 days) QL (60 tabs / 30 days) QL (30 tabs / 30 days)

VAGINAL ANTI-INFECTIVES clindamycin phosphate vaginal clotrimazole vaginal metronidazole vaginal miconazole nitrate vaginal CREA miconazole nitrate vaginal KIT miconazole nitrate vaginal SUPP 100mg povidone-iodine vaginal terconazole vaginal tioconazole vaginal VANDAZOLE zazole .4% ZAZOLE .8%

NM; * NM; * NM; * NM; * NM; * NM; *

HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS ANTICOAGULANTS - BLOOD THINNERS COUMADIN ELIQUIS enoxaparin sodium 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml enoxaparin sodium 100mg/ml, 120mg/0.8ml, 150mg/ml fondaparinux sodium 2.5mg/0.5ml fondaparinux sodium 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml HEPARIN SOD (PORCINE) IN D5W heparin sod inj 1000/ml HEPARIN SOD INJ 2000/ML HEPARIN SOD INJ 2500/ML heparin sod inj 5000/ml heparin sod inj 10000/ml heparin sod inj 20000/ml

2 2 1

$0 $0 $0

2

$0

1

$0

2

$0

2 1 2 2 1 1 1

$0 $0 $0 $0 $0 $0 $0

B/D B/D B/D B/D B/D B/D

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

49

Drug Name

HEPARIN SODIUM/D5W HEPARIN SODIUM/NACL 0.45% jantoven PRADAXA warfarin sodium XARELTO XARELTO STARTER PACK

Drug Tier 2 2 1 2 1 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0

HEMATOPOIETIC GROWTH FACTORS GRANIX LEUKINE MOZOBIL NEUMEGA NEUPOGEN PROCRIT

2 2 2 2 2 2

$0 $0 $0 $0 $0 $0

NM, NM, NM, NM NM, NM,

PA PA PA

3 3 3 3 3 3

$0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM;

* * * * * *

3

$0

NM; *

3 3 3 3 3 3

$0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM;

* * * * * *

3 3 3 3 3 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * * *

PA PA

IRON carbonyl iron ferretts FERRETTS IPS FERRIMIN 150 FERROUS FUMARATE TABS FERROUS GLUCONATE TABS 225mg, 324mg ferrous gluconate TABS 240mg, 324mg ferrous sulfate ELIX FERROUS SULFATE LIQD ferrous sulfate SOLN FERROUS SULFATE SYRP ferrous sulfate TABS ferrous sulfate TBCR 45mg, 47.5mg FERROUS SULFATE TBCR 140mg FERROUS SULFATE TBEC 324mg ferrous sulfate TBEC 325mg ferrous sulfate dried FOLGARD folic acid-vitamin b6-vitamin b12 FOLITAB 500 INTEGRA IRON TABS 90mg, 256mg IRON CHEWS PEDIATRIC IRON UP

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

50

Drug Name

Drug Tier 3 3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; * $0 NM; *

3 3 3 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM;

anagrelide hcl cilostazol CINRYZE FIRAZYR pentoxifylline TBCR PROMACTA 12.5mg

1 1 2 2 1 2

$0 $0 $0 $0 $0 $0

NM, LA, PA NM, PA

PROMACTA

25mg

2

$0

PROMACTA

50mg

2

$0

PROMACTA

75mg

2

$0

1

$0

iron-vitamin c iron-vitamin c-vitamin b12-folic acid MYKIDZ IRON 10 NOVAFERRUM 125 NOVAFERRUM PEDIATRIC DROP polysaccharide iron complex PROFE slow release iron 50mg SLOW RELEASE IRON 140mg SM SLOW RELEASE IRON VITAMIN B12/FOLIC ACID

* * * * * * * * *

MISCELLANEOUS

tranexamic acid SOLN; TABS

QL (360 tabs / 30 days), NM, LA, PA QL (180 tabs / 30 days), NM, LA, PA QL (90 tabs / 30 days), NM, LA, PA QL (60 tabs / 30 days), NM, LA, PA

PLATELET AGGREGATION INHIBITORS AGGRENOX ASPIRIN-DIPYRIDAMOLE BRILINTA clopidogrel bisulfate 75mg EFFIENT ZONTIVITY

2 1 2 1 2 2

$0 $0 $0 $0 $0 $0

IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) - DRUGS TO TREAT RHEUMATOID ARTHRITIS CIMZIA CIMZIA STARTER KIT HUMIRA HUMIRA KIT 40MG/0.8

2 2 2 2

$0 $0 $0 $0

NM, NM, NM, NM,

PA PA PA PA

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

51

Drug Name

Drug Tier

HUMIRA PEDIATRIC CROHNS HUMIRA PEN HUMIRA PEN-CROHNS DISEASE HUMIRA PEN-PSORIASIS STAR hydroxychloroquine sulfate leflunomide TABS methotrexate sodium tabs REMICADE

2 2 2 2 1 1 1 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM, PA $0 NM, PA $0 NM, PA $0 NM, PA $0 $0 $0 $0 NM, PA

2 2 2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0

NM, PA NM, PA NM, PA NM, PA B/D, NM NM, PA NM, PA NM, PA NM, PA

2 2

$0 $0

NM, PA NM, PA

2

$0

NM, PA

2 2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0

NM, LA, PA NM, PA B/D, NM B/D, NM B/D, NM B/D, NM NM, LA, PA NM, PA

1 2 1 1

$0 $0 $0 $0

B/D NM, PA B/D B/D

1 1

$0 $0

B/D B/D

IMMUNOGLOBULINS BIVIGAM CARIMUNE NANOFILTERED FLEBOGAMMA FLEBOGAMMA DIF GAMASTAN S/D GAMMAGARD LIQUID GAMMAGARD S/D GAMMAKED GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 10gm/200ml GAMUNEX-C OCTAGAM 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml PRIVIGEN

IMMUNOMODULATORS ACTIMMUNE ARCALYST INTRON-A INJ INTRON-A INJ INTRON-A INJ INTRON-A INJ REVLIMID THALOMID

10MU 18MU 25MU 50MU

IMMUNOSUPPRESSANTS azathioprine TABS BENLYSTA cyclosporine CAPS; SOLN cyclosporine modified (for microemulsion) gengraf mycophenolate mofetil CAPS; TABS

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

52

Drug Name

mycophenolate mofetil SUSR mycophenolate sodium 180mg mycophenolate sodium 360mg NEORAL NULOJIX PROGRAF CAPS RAPAMUNE SOLN SANDIMMUNE SOLN 100mg/ml SIROLIMUS TABS 2mg sirolimus TABS .5mg, 1mg tacrolimus CAPS 5mg tacrolimus CAPS .5mg, 1mg ZORTRESS TAB 0.5MG ZORTRESS TAB 0.25MG ZORTRESS TAB 0.75MG

Drug Tier 2 1 2 2 2 2 2 2 2 1 2 1 2 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D $0 B/D

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

VACCINES ACTHIB ADACEL BCG VACCINE BEXSERO BOOSTRIX CERVARIX COMVAX DAPTACEL DIPHTHERIA/TETANUS TOXOID ENGERIX-B SUSP GARDASIL GARDASIL 9 HAVRIX HIBERIX IMOVAX RABIES (H.D.C.V.) INFANRIX IPOL INACTIVATED IPV IXIARO KINRIX M-M-R II MENACTRA MENOMUNE-A/C/Y/W-135 MENVEO PEDIARIX PEDVAX HIB PENTACEL

B/D B/D

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

53

Drug Name

PROQUAD QUADRACEL RABAVERT RECOMBIVAX HB ROTARIX ROTATEQ SYNAGIS TENIVAC TETANUS/DIPHTHERIA TOXOID TRUMENBA TWINRIX INJ TYPHIM VI VAQTA VARIVAX YF-VAX ZOSTAVAX

Drug Tier 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 B/D $0 $0 $0 NM $0 B/D $0 B/D $0 $0 $0 $0 $0 $0 $0 QL (1 vial per lifetime)

NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS ELECTROLYTES KLOR-CON 8 1 KLOR-CON 10 1 klor-con m10 1 klor-con m15 1 klor-con m20 1 klor-con pow 20meq 1 klor-con spr cap 8meq 1 klor-con spr cap 10meq 1 MAGNESIUM SULFATE SOLN 2 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml magnesium sulfate SOLN 50% 1 MAGNESIUM SULFATE SOLN 50% 1 MAGNESIUM SULFATE IN D5W 2 oral electrolytes 3 potassium chloride CPCR 1 POTASSIUM CHLORIDE SOLN 1 10%, 20% potassium chloride TBCR 8meq 1 POTASSIUM CHLORIDE TBCR 1 20meq potassium chloride 1 microencapsulated crystals cr

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; *

$0 $0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

54

Drug Name

POTASSIUM CHLORIDE TAB CR 10 MEQ SODIUM CHLORIDE SOLN 2.5meq/ml SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN TPN ELECTROLYTES

Drug Tier 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0

1

$0

1

$0

2

$0

B/D

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 1 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D B/D

1 1

$0 $0

IV NUTRITION AMINOSYN AMINOSYN 7%/ELECTROLYTES AMINOSYN 8.5%/ELECTROLYTE AMINOSYN II AMINOSYN II 8.5%/ELECTROL AMINOSYN M AMINOSYN-HBC AMINOSYN-PF 7% AMINOSYN-PF INJ 10% AMINOSYN-RF CLINIMIX 2.75%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 5% CLINIMIX 4.25%/DEXTROSE 25% CLINIMIX 5%/DEXTROSE 15% CLINIMIX 5%/DEXTROSE 20% CLINIMIX 5%/DEXTROSE 25% CLINIMIX INJ 4.25/D10 CLINIMIX INJ 4.25/D20 FREAMINE HBC 6.9% FREAMINE III HEPATAMINE INTRALIPID INJ 20% INTRALIPID INJ 30% NEPHRAMINE NUTRILIPID INJ 20% premasol sol 6% premasol sol 10% PROCALAMINE PROSOL TRAVASOL TROPHAMINE INJ 10%

IV REPLACEMENT SOLUTIONS DEXTROSE 2.5%/NACL 0.45% DEXTROSE 5%

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

55

Drug Name

DEXTROSE 5% /ELECTROLYTE DEXTROSE 5%/LACTATED RING DEXTROSE 5%/NACL 0.2% DEXTROSE 5%/NACL 0.3% DEXTROSE 5%/NACL 0.9% DEXTROSE 5%/NACL 0.33% DEXTROSE 5%/NACL 0.45% DEXTROSE 5%/NACL 0.225% DEXTROSE 5%/POTASSIUM CHL DEXTROSE 10% FLEX CONTAIN DEXTROSE 10%/NACL 0.2% DEXTROSE 10%/NACL 0.45% DEXTROSE 50% DEXTROSE INJ 70% IONOSOL-B/DEXTROSE 5% IONOSOL-MB/DEXTROSE 5% ISOLYTE P ISOLYTE S KCL0.15%/D5W/NACL0.2% KCL0.15%/D5W/NACL0.225% KCL 0.3%/D5W/NACL 0.9% KCL 0.3%/D5W/NACL 0.45% KCL 0.15%/D5W/NACL 0.9% KCL 0.075%/D5W/NACL 0.45% KCL IN NACL INJ .15-0.45 KCL/D5W INJ 0.3% KCL/D5W/NACL INJ 0.22%/0.45% KCL/D5W/NACL INJ .15/.33% KCL/D5W/NACL INJ .15/.45% KCL/NACL INJ 0.3-0.9 KCL/NACL INJ 0.15%-0.9% LACTATED RINGER'S INJ NORMOSOL-M IN D5W NORMOSOL-R NORMOSOL-R IN D5W PLASMA-LYTE A PLASMA-LYTE-56/D5W PLASMA-LYTE-148 pot chloride inj 2meq/ml

Drug Tier 2 1 1 1 1 1 1 1 1 1 2 1 1 1 2 2 2 2 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

56

Drug Name

Drug Tier

POTASSIUM CHLORIDE SOLN 1 .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml potassium chloride in nacl 1 RINGER'S 1 SODIUM CHLORIDE SOLN 3%, 5%1 SODIUM CHLORIDE 0.45% VIA 1 SODIUM CHLORIDE INJ 0.9% 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0

$0 $0 $0 $0 $0

MINERALS ADVANCED CALCIUM FORMULA BONE DENSITY bone meal w/ vitamin d CAL-CITRATE PLUS VITAMIN CAL-QUICK CAL/MAG CALCET CREAMY BITES CALCET PETITES CALCI-MIX CALCIONATE calcium TABS 500mg CALCIUM 500 CALCIUM 1000 + D CALCIUM & MAGNESIUM CALCIUM CARBONATE CHEW CALCIUM CARBONATE POWD calcium carbonate SUSP calcium carbonate TABS 600mg, 1250mg calcium carbonate-cholecalciferol calcium carbonate-ergocalciferol calcium carbonate-vitamin d calcium carbonate-vitamin d w/ minerals CALCIUM CITRATE GRAN CALCIUM CITRATE TABS 250mg CALCIUM CITRATE MALATE/VI CALCIUM CITRATE W/D calcium citrate-vitamin d CALCIUM GLUCONATE TABS 50mg, 500mg calcium gluconate TABS 500mg

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * * * * * * * * * *

3 3 3 3

$0 $0 $0 $0

NM; NM; NM; NM;

* * * *

3 3 3 3 3 3

$0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM;

* * * * * *

3

$0

NM; *

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

57

Drug Name

Drug Tier

CALCIUM GUMMIES 3 CALCIUM LACTATE 100mg, 3 648mg calcium lactate 650mg 3 calcium w/ magnesium 3 calcium w/ vitamins d & k 3 calcium-magnesium w/ vitamin d 3 calcium-magnesium-zinc 3 CALCIUM/C/D 3 CALCIUM/MAGNESIUM/VITAMIN 3 CALCIUM/MAGNESIUM/ZINC 3 CALMAG THINS 3 CALTRATE 600+D SOFT CHEWS 3 CHELATED CALCIUM 3 CITRACAL CALCIUM GUMMIES 3 CITRACAL PLUS HEART HEALT 3 CORAL CALCIUM CAPS 3 CORAL CALCIUM PLUS 3 coral calcium-magnesium w/ 3 vitamin d CVS CALCIUM CITRATE 3 EQL CALCIUM/VITAMIN D 3 EQL CHILDRENS CALCIUM GUM 3 LIQUID CALCIUM WITH D3 MA 3 LOCALNESIUM 3 LOCALNESIUM-C 3 MAG-TAB SR 3 MAGINEX 3 MAGNEBIND 300 3 MAGNESIUM CAPS 400mg 3 magnesium TABS 200mg 3 magnesium chloride TBCR 3 magnesium chloride-calcium 3 MAGNESIUM CITRATE TABS 3 MAGNESIUM ELEMENTAL 3 magnesium oxide (mg supplement)3 OSTEO-PORETICAL 3 oyster shell 3 PARVA-CAL 3 PHOS-NAK POWDER CONCENTRA 3 RA CALCIUM/BORON 3 RA OYSTER SHELL CALCIUM/V 3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; * $0 NM; * $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * * * * * * * *

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * * * * * * * * * * * * * *

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

58

Drug Name

selenium TABS 100mcg SELENIUM TBCR SLOW-MAG SM CORAL CALCIUM UPCAL D

Drug Tier 3 3 3 3 3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; * $0 NM; * $0 NM; * $0 NM; * $0 NM; *

3 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM;

* * * * * * *

3 3 3 3 3 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * * *

3 3 1 1 1 3 3

$0 $0 $0 $0 $0 $0 $0

NM; NM; B/D B/D B/D NM; NM;

* *

3 3 3 3 3

$0 $0 $0 $0 $0

NM; NM; NM; NM; NM;

* * * * *

3

$0

NM; *

VITAMINS ACEROLA C 500 ANTIOXIDANT FORMULA SG AQUA-E ascorbic acid CHEW ascorbic acid LOZG ASCORBIC ACID POWD ascorbic acid TABS 100mg, 250mg, 500mg ascorbic acid TBCR b complex w/ c B-12 DOTS B-12 QUICK DISSOLVE b-complex vitamins b-complex w/ c & calcium b-complex w/ c & e + zn b-complex w/ c & folic acid b-complex w/ minerals B-NATAL beta carotene CAPS 15mg, 25000unit biotin CAPS 5mg biotin TABS 300mcg calcitriol CAPS calcitriol inj calcitriol oral soln 1 mcg/ml calcium ascorbate TABS calcium pantothenate TABS 500mg CENTRUM SILVER CHEW cholecalciferol CAPS cholecalciferol CHEW cholecalciferol LIQD cholecalciferol TABS 400unit, 1000unit, 2000unit, 5000unit CHOLECALCIFEROL TABS 50000unit

* *

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

59

Drug Name

Drug Tier

CLASSIC PRENATAL 3 cod liver oil CAPS 3 CVS VITAMIN C CHEW 3 cyanocobalamin LIQD; SOLN; 3 SUBL; TABS; TBCR; TBDP CYTO B2 3 DIALYVITE 800/ZINC 15 3 ELDERTONIC 3 EQL CHILDRENS MULTIVITAMI 3 ergocalciferol CAPS 3 EZFE FORTE 3 FOLIC ACID CAPS 20mg 3 folic acid SOLN 3 FOLIC ACID TABS 1mg 3 folic acid TABS 1mg, 400mcg, 3 800mcg HONEY BEARS 3 HONEY BEARS W/IRON AND ZI 3 hydroxocobalamin SOLN 3 ICAPS LUTEIN/ZEAXANTHIN F 3 iron w/ vitamins 3 KPN PRENATAL 3 LUMITENE 3 MEPHYTON 3 MISSION PRENATAL 3 MISSION PRENATAL HP 3 MULTI-DELYN/IRON 3 multiple vitamins w/ iron 3 multiple vitamins w/ minerals 3 MYKIDZ IRON 3 NASCOBAL 3 NEPHRONEX LIQD 3 niacin CPCR 3 niacin TABS 50mg, 100mg, 3 500mg niacin TBCR 3 NIACIN TR 3 niacinamide TABS 3 paricalcitol CAPS 1 pediatric multiple vitamin w/ c 3 pediatric multiple vitamin w/ c & fa 3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; * $0 NM; * $0 NM; * $0 NM; * $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * *

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * * * * * * * * * *

$0 $0 $0 $0 $0 $0

NM; NM; NM; B/D NM; NM;

* * * * *

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

60

Drug Name

Drug Tier

pediatric multiple vitamin w/ extra c3 & fa pediatric multiple vitamin w/ 3 minerals & c pediatric multiple vitamins 3 pediatric multiple vitamins w/ iron 3 pediatric vitamins adc 3 PERRY PRENATAL 3 phytonadione SOLN; TABS 3 PRENATAL 3 PRENATAL VITAMIN/FOLIC ACID > 1 0.8 MG (GENERIC) pyridoxine hcl SOLN; TABS; TBCR 3 riboflavin TABS 25mg, 50mg 3 SCOOBY-DOO ONE A DAY 3 SM VITAMIN D3 MAXIMUM STR 3 specialty vitamins products 3 THERA-D 4000 3 THERA/BETA-CAROTENE 3 THERANATAL CORE NUTRITION 3 thiamine hcl SOLN; TABS 3 thiamine mononitrate 3 TRI-VI-SOL 3 VITALETS 3 VITAMIN A PALMITATE TABS 3 15000unit VITAMIN C SOLR 3 vitamin c SYRP 3 VITAMIN D2 3 VITAMIN D3 LIQD 1200unit/15ml 3 VITAMIN D3 TABS 3 vitamin e CAPS 100unit, 200unit, 3 1000unit vitamin e OIL 3 vitamin e SOLN 3 VITAMIN E TABS 100unit 3 vitamin mixture 3 vitamins a & d CAPS 3 ZOO FRIENDS COMPLETE 3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; * $0

NM; *

$0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM;

* * * * * *

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * * * * *

$0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM;

* * * * * *

$0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM;

* * * * * *

OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS TO TREAT INFECTIONS AND INFLAMMATION PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

61

Drug Name

bacitracin-poly-neomycin-hc blephamide OINT neomycin-polymy-dexameth neomycin-polymyxin-hc (ophth) sulfacetamide sod-prednisolone TOBRADEX OINT TOBRADEX ST tobramycin-dexamethasone ZYLET

Drug Tier 1 2 1 1 1 2 2 1 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0 $0 $0

ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS bacitracin (ophthalmic) bacitracin-polymyxin b (ophth) BESIVANCE CILOXAN OINT ciprofloxacin hcl (ophth) erythromycin (ophth) gatifloxacin (ophth) gentak gentamicin sulfate (ophth) ilotycin MOXEZA NATACYN neomycin-bacitracin zn-polymyxin neomycin-polymyxin-gramicidin ofloxacin (ophth) polymyxin b-trimethoprim sulfacet sod oin 10% op sulfacetamide sodium (ophth) tobramycin (ophth) TOBREX OINT trifluridine SOLN VIGAMOX ZIRGAN

1 1 2 2 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 2 1 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

ANTI-INFLAMMATORIES - DRUGS TO TREAT INFLAMMATION ALREX bromfenac sodium (ophth) BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) dexamethasone sodium phosphate (ophth) diclofenac sodium (ophth) DUREZOL

2 1 1

$0 $0 $0

1

$0

1 2

$0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

62

Drug Name

Drug Tier

FLUOROMETHOLONE 1 flurbiprofen sodium 1 ILEVRO 2 ketorolac tromethamine (ophth) 1 LOTEMAX 2 MAXIDEX 2 PREDNISOLONE ACETATE (OPHTH) 1 prednisolone sodium phosphate 2 (ophth)

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0 $0

ANTIALLERGICS - DRUGS TO TREAT ALLERGIES azelastine drop 0.05% BEPREVE cromolyn sodium (ophth) ketotifen fumarate (ophth) LASTACAFT NAPHAZOLINE W/ PHENIRAMINE naphazoline-glycerin PATADAY PAZEO tetrahydrozoline hcl (ophth) tetrahydrozoline w/ zinc sulfate VISINE-LR

1 2 1 3 2 3 3 2 2 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; * NM; * NM; *

NM; * NM; * NM; *

ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA ALPHAGAN P SOL 0.1% AZOPT betaxolol hcl (ophth) BETOPTIC-S brimonidine sol 0.2% BRIMONIDINE SOL 0.15% carteolol hcl (ophth) COMBIGAN dorzolamide hcl dorzolamide hcl-timolol maleate ISTALOL latanoprost SOLN levobunolol hcl .5% LUMIGAN metipranolol PHOSPHOLINE IODIDE PILOCARPINE HCL SOLN SIMBRINZA timolol maleate (ophth)

2 2 1 2 1 1 1 2 1 1 2 1 1 2 1 2 1 2 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

63

Drug Name

TIMOLOL MALEATE GEL TRAVATAN Z

Drug Tier 1 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0

3 3

$0 $0

NM; * NM; *

3 3 3 3

$0 $0 $0 $0

NM; NM; NM; NM;

* * * *

3 3 3 3 3 1 3 3

$0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM;

* * * * *

3 3 2 1 3 3 3 2 3 3 3 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; * NM; *

MISCELLANEOUS artificial tear ointment carboxymethylcellulose sodium (ophth) carboxymethylcellulose-glycerin ENUCLENE FRESHKOTE glycerin-hypromellose-polyethylen e glycol 400 HYPOTEARS hypromellose (gonioscopic) hypromellose (ophth) ISOPTO TEARS MURO 128 SOLN 2% naphazoline 0.1% ophthalmic irrigation solution polyethylene glycol-propylene glycol (ophth) polyvinyl alcohol SOLN polyvinyl alcohol-povidone (ophth) PROLENSA proparacaine hcl SOLN propylene glycol-glycerin REFRESH CELLUVISC REFRESH OPTIVE ADVANCED RESTASIS RETAINE MGD sodium chloride hypertonic SOOTHE STERILE LUBRICANT DROPS SYSTANE BALANCE RESTORATI SYSTANE OVERNIGHT THERAPY TEARS AGAIN NIGHT & DAY THERATEARS SOLN white petrolatum-mineral oil

NM; * NM; *

NM; * NM; * NM; * QL (64 vials / 30 days) NM; * NM; * NM; * NM; * NM; * NM; * NM; * NM; * NM; *

RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS ANTICHOLINERGIC/BETA AGONIST COMBINATIONS - DRUGS TO TREAT COPD ANORO ELLIPTA

2

$0

QL (60 inhalations / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

64

Drug Name

Drug Tier

COMBIVENT RESPIMAT

2

ipratropium-albuterol nebu

1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (2 inhalers / 30 days) $0 B/D

ANTICHOLINERGICS - DRUGS TO TREAT COPD ATROVENT HFA

2

$0

INCRUSE ELLIPTA ipratropium bromide SOLN ipratropium bromide (nasal)

2 1 1

$0 $0 $0

QL (2 inhalers / 30 days) QL (1 inhaler / 30 days) B/D

ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES ALA-HIST IR ALLEGRA ALLERGY CHILDRENS TABS ASTEPRO azelastine spr 0.1% azelastine spr 0.15% cetirizine hcl cetirizine syrup chlorpheniramine maleate SYRP; TBCR CLARITIN CHEW CLARITIN REDITABS 5mg diphenhydramine hcl CAPS diphenhydramine hcl CHEW diphenhydramine hcl LIQD diphenhydramine hcl TABS 25mg diphenhydramine hcl TBDP diphenhydramine inj ED CHLORPED fexofenadine hcl SUSP; TABS hydroxyzine hcl SOLN; SYRP; TABS hydroxyzine pamoate CAPS

3 3

$0 $0

2 1 1 3 1 3

$0 $0 $0 $0 $0 $0

3 3 3 3 3 3 3 1 3 3 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

2

$0

J-TAN PD levocetirizine dihydrochloride loratadine SYRP; TABS olopatadine hcl (nasal) TRIAMINIC COUGH & RUNNY N STRP

3 1 3 1 3

$0 $0 $0 $0 $0

NM; * NM; *

NM; * NM; * NM; NM; NM; NM; NM; NM; NM;

* * * * * * *

NM; * NM; * PA; PA if 65 years and older PA; PA if 65 years and older NM; * NM; * NM; *

BETA AGONISTS - DRUGS TO TREAT ASTHMA AND COPD albuterol sulfate

NEBU

1

$0

B/D

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

65

Drug Name

albuterol sulfate SYRP; TABS; TB12 levalbuterol conc 1.25mg/0.5ml PERFOROMIST SEREVENT DISKUS

1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0

1 2 2

$0 $0 $0

terbutaline sulfate terbutaline sulfate VENTOLIN HFA

2 1 2

$0 $0 $0

2

$0

acetaminophen w/ dm 3 ADVIL ALLERGY & CONGESTIO 3 ADVIL ALLERGY SINUS 3 ADVIL COLD & SINUS CAPS 3 ALA-HIST PE 3 AYR NASAL DROPS 3 benzonatate 100mg, 200mg 3 BIOSPEC DMX 3 BROHIST D 3 brompheniramine & phenyleph 3 brompheniramine & pseudoeph 3 cetirizine-pseudoephedrine 3 CHLO TUSS EX 3 chlorpheniramine & phenylephrine 3 chlorpheniramine & pseudoeph 3 chlorpheniramine-dm 3 chlorpheniramine-phenylephrine-ac 3 etaminophen CODITUSS DM 3 COMPLETE SINUS RELIEF 3 CONEX COLD/ALLERGY 3 CONTAC COLD/FLU MAXIMUM S 3 cromolyn sodium (nasal) 3 CVS NASAL MIST .9% 3 DELTUSS DP 3 dextromethorphan hbr CAPS; 3 LIQD; SYRP dextromethorphan polistirex 3 dextromethorphan-guaifenesin 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * * * * * * * * *

$0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * *

$0 $0

NM; * NM; *

XOPENEX HFA

Drug Tier

SOLN TABS

B/D B/D QL (60 inhalations / 30 days)

QL (2 inhalers / 30 days) QL (2 inhalers / 30 days)

COUGH AND COLD

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

66

Drug Name

Drug Tier

dextromethorphan-phenylephrine- 3 acetaminophen DIMETAPP LONG ACTING COUG 3 diphenhydramine-acetaminophen 3 diphenhydramine-phenylephrine 3 diphenhydramine-phenylephrine-ac 3 etaminophen doxylamine-phenylephrine-acetami 3 nophen DURAFLU 3 ED CHLORPED D 3 fexofenadine-pseudoephedrine 3 guaifenesin LIQD; TABS; TB12 3 guaifenesin-codeine 3 J-MAX 3 J-TAN D PD 3 LODRANE D 3 LOHIST-D 3 loratadine & pseudoephedrine 3 M-END DMX 3 MUCINEX COUGH FOR KIDS 3 MUCINEX D 3 MUCINEX D MAXIMUM STRENGT 3 MUCINEX FOR KIDS 3 MUCINEX MAXIMUM STRENGTH 3 NASAL DECONGESTANT LIQD 3 NASOPEN PE 3 NEXAFED SINUS PRESSURE + 3 NOREL AD 3 oxymetazoline hcl SOLN 3 PHENAGIL 3 phenylephrine hcl SOLN .25% 3 phenylephrine hcl (oral) 3 phenylephrine w/ acetaminophen 3 phenylephrine w/ dm-gg 3 phenylephrine-acetaminophen-guai 3 fenesin phenylephrine-brompheniramine-d 3 m phenylephrine-chlorphen-dm 3 phenylephrine-chlorpheniramine-d 3 m w/ apap phenylephrine-dm 3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; * $0 $0 $0 $0

NM; NM; NM; NM;

* * * *

$0

NM; *

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

$0

NM; *

$0 $0

NM; * NM; *

$0

NM; *

* * * * * * * * * * * * * * * * * * * * * * * * * * *

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

67

Drug Name

phenylephrine-dm-gg w/ apap phenylephrine-doxylamine-dextro methorphan-acetaminophen phenylephrine-guaifenesin PRETZ PRO-CHLO pseudoephed-bromphen-dm pseudoephed-doxyl-dm w/apap pseudoephedrine hcl LIQD pseudoephedrine hcl SYRP pseudoephedrine hcl TABA pseudoephedrine hcl TABS 60mg pseudoephedrine hcl TB12 pseudoephedrine w/ dm-gg pseudoephedrine-chlorphen-dm pseudoephedrine-dexchlorphenira mine-chlophedianol pseudoephedrine-guaifenesin pyrilamine maleate-phenylephrine hcl tannate pyrilamine-phenylephrine RESCON RESCON DM RESPAIRE-30 RHINARIS ROBITUSSIN CHILDRENS COUG ROBITUSSIN PEAK COLD NIGH LIQD RYMED saline GEL SCOT-TUSSIN SENIOR STAHIST AD TRIAMINIC NIGHT TIME COLD triprolidine & pseudoephedrine TUSNEL LIQD TUSNEL PEDIATRIC TUSNEL-DM PEDIATRIC VICKS VAPORUB zonatuss

Drug Tier 3 3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; * $0 NM; *

3 3 3 3 3 3 3 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

3 3

$0 $0

NM; * NM; *

3 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM;

* * * * * * *

3 3 3 3 3 3 3 3 3 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * * *

* * * * * * * * * * * * *

LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS TO TREAT ASTHMA AND ALLERGIES

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

68

Drug Name

montelukast sodium CHEW; PACK; TABS zafirlukast

Drug Tier 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0

1

$0

MAST CELL STABILIZERS - DRUGS TO TREAT ALLERGIES cromolyn sodium nebu

1

$0

B/D

1 2 2 2 2 2 2 2 2 2 2 2 2

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

B/D NM, LA, PA

MISCELLANEOUS acetylcysteine SOLN 10%, 20% ARALAST NP DALIRESP EPIPEN 2-PAK EPIPEN-JR 2-PAK ESBRIET KALYDECO OFEV ORKAMBI PROLASTIN-C PULMOZYME XOLAIR ZEMAIRA

NM, PA NM, PA NM, PA NM, PA NM, LA, PA B/D, NM NM, LA, PA NM, LA, PA

NASAL STEROIDS - DRUGS TO TREAT ALLERGIES flunisolide (nasal) fluticasone propionate (nasal) mometasone furoate (nasal) NASONEX

1 1 1 2

$0 $0 $0 $0

QL (2 QL (1 QL (2 QL (2 days)

bottles / 30 days) bottle / 30 days) bottles / 30 days) inhalers / 30

STEROID INHALANTS - DRUGS TO TREAT ASTHMA ARNUITY ELLIPTA

2

$0

budesonide (inhalation) .25mg/2ml, .5mg/2ml FLOVENT DISKUS 50mcg/blist, 100mcg/blist FLOVENT DISKUS 250mcg/blist

1

$0

2

$0

2

$0

FLOVENT HFA

2

$0

PULMICORT FLEXHALER

2

$0

QL (30 inhalations / 30 days) B/D QL (120 inhalations / 30 days) QL (240 inhalations / 30 days) QL (2 inhalers / 30 days) QL (2 inhalers / 30 days)

STEROID/BETA-AGONIST COMBINATIONS - DRUGS TO TREAT ASTHMA AND COPD ADVAIR DISKUS

2

$0

QL (60 inhalations / 30 days)

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

69

Drug Name

Drug Tier

ADVAIR HFA BREO ELLIPTA

2 2

SYMBICORT

2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 QL (1 inhaler / 30 days) $0 QL (60 blisters / 30 days) $0 QL (1 inhaler / 30 days)

XANTHINES - DRUGS TO TREAT COPD aminophylline inj elixophyllin theo-24 theophylline

1 2 2 1

TOPICAL - DRUGS TO TREAT EAR DERMATOLOGY, ACNE adapalene CREA adapalene GEL .1% amnesteem AVITA benzoyl peroxide-erythromycin claravis clindamax clindamycin phosphate (topical) GEL; LOTN; SOLN; SWAB ery pad 2% erythromycin (acne aid) myorisan sulfacetamide sodium (acne) tretinoin CREA TRETINOIN GEL .01% tretinoin GEL .025% zenatane

$0 $0 $0 $0

AND SKIN CONDITIONS

1 1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0

1 1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0

3 3 3 3 3 3 3 3 3 3 1 1 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

DERMATOLOGY, ANTIBIOTICS ACNE MEDICATION ACNE MEDICATION 5 bacitracin (topical) bacitracin zinc OINT bacitracin-polymyxin b benzoyl peroxide BAR BENZOYL PEROXIDE GEL 2.5% benzoyl peroxide GEL 5%, 10% benzoyl peroxide LIQD benzoyl peroxide LOTN gentamicin sulfate (topical) mupirocin OINT neomycin-bacitracin-polymyxin

NM; NM; NM; NM; NM; NM; NM; NM; NM; NM;

* * * * * * * * * *

NM; *

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

70

Drug Name

PANOXYL-4 CREAMY WASH SILVER SULFADIAZINE CREA SSD SULFAMYLON

Drug Tier 3 1 1 2

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; * $0 $0 $0

DERMATOLOGY, ANTIFUNGALS castellani paint 3 ciclopirox CREA; GEL; SUSP 1 ciclopirox shampoo 1% 1 clotrimazole (topical) CREA 1 clotrimazole (topical) SOLN 1% 1 clotrimazole (topical) SOLN 1% 3 econazole nitrate CREA 1 FUNGOID TINCTURE 3 GENTIAN VIOLET SOLN 3 hydrocortisone (topical) CREA 1% 3 ketoconazole cream 1 LAMISIL ADVANCED 3 LOTRIMIN ULTRA 3 miconazole nitrate (topical) 3 nyamyc 1 nystatin (topical) 1 nystop 1 terbinafine hcl (topical) 3 tolnaftate 3 zinc oxide (topical) OINT 40% 3

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; *

NM; * NM; * NM; * NM; * NM; * NM; * NM; *

NM; * NM; * NM; *

DERMATOLOGY, ANTIPRURITIC DOXEPIN HCL (ANTIPRURITIC) procto-pak proctosol hc cre 2.5% proctozone hc PRUDOXIN CRE 5%

1 1 1 1 1

$0 $0 $0 $0 $0

DERMATOLOGY, ANTIPSORIATICS acitretin 2 calcipotriene CREA; OINT; SOLN 1 calcitrene oin 0.005% 1 8-MOP 2 TAZORAC CREA 2

$0 $0 $0 $0 $0

PA

PA

DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo selenium sulfide LOTN

1 1

$0 $0

DERMATOLOGY, CORTICOSTEROIDS PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

71

Drug Name

Drug Tier

ala-cort 1 alclometasone dipropionate 1 betamethasone dipropionate 1 (topical) betamethasone dipropionate 1 augmented betamethasone valerate CREA; 1 LOTN; OINT clobetasol e cream 0.05% 1 clobetasol propionate CREA 1 clobetasol propionate GEL 1 clobetasol propionate OINT 1 clobetasol propionate SOLN 1 cormax 1 CVS HDYROCORTISONE ACETAT 3 DESONIDE CREA 1 desonide LOTN; OINT 1 desoximetasone CREA 1 desoximetasone GEL 1 DESOXIMETASONE OINT .05% 1 desoximetasone OINT .25% 1 diflorasone diacetate 1 fluocinolone acetonide CREA; OIL;1 OINT; SOLN fluocinonide CREA .05% 1 fluocinonide GEL 1 fluocinonide OINT 1 fluocinonide SOLN 1 fluocinonide emulsified base 1 fluticasone propionate CREA 1 fluticasone propionate OINT 1 halobetasol propionate 1 hydrocortisone (topical) CREA 1 1%, 2.5% hydrocortisone (topical) CREA 3 .5% hydrocortisone (topical) GEL 3 hydrocortisone (topical) LOTN 1% 3 hydrocortisone (topical) LOTN 1 2.5% hydrocortisone (topical) OINT 1%,1 2.5%

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; *

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0

NM; *

$0 $0 $0

NM; * NM; *

$0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

72

Drug Name

Drug Tier

hydrocortisone (topical) OINT 3 .5%, 1% hydrocortisone acetate-aloe vera 3 hydrocortisone butyrate 1 hydrocortisone valerate 1 hydrocortisone-aloe vera 3 lokara 1 mometasone furoate CREA; OINT;1 SOLN texacort soln 2.5% 2 triamcinolone acetonide (topical) 1 CREA; LOTN; OINT triderm 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 NM; * $0 $0 $0 $0 $0 $0

NM; *

NM; *

$0 $0 $0

DERMATOLOGY, LOCAL ANESTHETICS lidocaine PTCH

1

$0

lidocaine hcl GEL lidocaine hcl SOLN 4% lidocaine oint 5% lidocaine-prilocaine

1 1 1 1

$0 $0 $0 $0

QL (3 patches / 1 day), PA

B/D

DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE ABREVA acyclovir topical ammonium lactate CREA; LOTN BOUDREAUXS BUTT PASTE DESITIN CREA diclofenac sodium (topical) 1% gel ELIDEL fluorouracil (topical) CREA 5% fluorouracil (topical) SOLN imiquimod CREA metronidazole (topical) CREA; LOTN metronidazole gel 0.75% MEXSANA PANRETIN podofilox SOLN RA CALAMINE LOTN RISAMINE rosadan cre 0.75% SECURA EXTRA PROTECTIVE SENSI-CARE PROTECTIVE BAR

3 1 1 3 3 1 2 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0

1 3 2 1 3 3 1 3 3

$0 $0 $0 $0 $0 $0 $0 $0 $0

NM; *

NM; * NM; * PA

NM; *

NM; * NM; * NM; * NM; *

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

73

Drug Name

tacrolimus (topical) TARGRETIN GEL TRIPLE PASTE VALCHLOR VOLTAREN ZINC OXIDE PSTE zinc oxide (topical) CREA zinc oxide (topical) OINT 20%

Drug Tier 1 2 3 2 2 3 3 3

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0 PA $0 NM, PA $0 NM; * $0 NM, LA, PA $0 $0 NM; * $0 NM; * $0 NM; *

DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX malathion permethrin CREA permethrin LIQD; LOTN permethrin & pyrethrins-piperonyl butoxide PYRETHINS/PIPERONYL BUTO pyrethrins-piperonyl butoxide RID ESSENTIAL LICE ELIMIN

2 1 1 3 3

$0 $0 $0 $0 $0

NM; * NM; *

3 3 3

$0 $0 $0

NM; * NM; * NM; *

DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% REGRANEX SANTYL SODIUM CHLORIDE 0.9% STERILE WATER IRRIGATION

1 2 2 1 1

$0 $0 $0 $0 $0

PA

MOUTH/THROAT/DENTAL AGENTS cevimeline hcl chlorhexidine gluconate (mouth-throat) clotrimazole TROC lidocaine hcl (mouth-throat) nystatin (mouth-throat) paroex sol 0.12% periogard PILOCARPINE HCL (ORAL) 5mg pilocarpine hcl (oral) 7.5mg triamcinolone acetonide (mouth)

1 1

$0 $0

1 1 1 1 1 1 1 1

$0 $0 $0 $0 $0 $0 $0 $0

OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR acetic acid (otic) acetic acid-aluminum acetate CIPRODEX fluocinolone acetonide (otic) neomycin-polymyxin-hc (otic)

1 1 2 1 1

$0 $0 $0 $0 $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

74

Drug Name

ofloxacin (otic)

Drug Tier 1

WHAT THE NECESSARY ACTIONS DRUG RESTRICTIONS OR WILL LIMITS ON USE COST YOU $0

PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access * - Non-Part D Drugs, or OTC items that are covered by Medicaid

75

Index 8 8-MOP .............................................71 A abacavir sulfate ................................. 6 abacavir sulfate-lamivudine-zidovudine 7 ABELCET ........................................... 5 ABILIFY DISCMELT TAB 10MG ............28 ABILIFY MAINTENA ...........................28 ABRAXANE .......................................12 ABREVA ...........................................73 acamprosate calcium .........................34 acarbose ..........................................36 acebutolol hcl ...................................19 ACEROLA C 500 ................................59 acetaminophen .................................. 1 ACETAMINOPHEN ............................... 1 ACETAMINOPHEN 8 HOUR ................... 1 acetaminophen w/ codeine .................. 2 acetaminophen w/ dm .......................66 acetazolamide ..................................21 acetic acid........................................74 acetic acid (otic) ...............................74 acetic acid-aluminum acetate .............74 acetylcysteine ..................................69 acitretin ...........................................71 ACNE MEDICATION ...........................70 ACNE MEDICATION 5 ........................70 ACTHIB ...........................................53 ACTIMMUNE .....................................52 acyclovir ........................................... 8 acyclovir sodium ................................ 8 acyclovir topical ................................73 ADACEL ...........................................53 ADAGEN ..........................................40 adapalene ........................................70 adefovir dipivoxil ............................... 8 ADEMPAS.........................................22 adrucil .............................................11 ADVAIR DISKUS ...............................69 ADVAIR HFA .....................................70 ADVANCED CALCIUM FORMULA ..........57 ADVIL ALLERGY & CONGESTIO ...........66 ADVIL ALLERGY SINUS ......................66 ADVIL COLD & SINUS ........................66 afeditab cr .......................................19 AFINITOR ........................................13 AFINITOR DISPERZ ...........................13

AGGRENOX ..................................... 51 a-hydrocort ..................................... 41 ala-cort ........................................... 72 ALA-HIST IR .................................... 65 ALA-HIST PE .................................... 66 ALBENZA........................................... 4 albuterol sulfate .......................... 65, 66 alclometasone dipropionate ............... 72 ALCOHOL SWABS ............................. 35 ALDURAZYME .................................. 40 ALECENSA ....................................... 13 alendronate sodium .......................... 37 alfuzosin hcl .................................... 48 ALIMTA ........................................... 11 ALINIA .............................................. 4 ALLEGRA ALLERGY CHILDRENS .......... 65 allopurinol tab.................................... 1 alosetron hcl .................................... 47 ALPHAGAN P SOL 0.1%..................... 63 alprazolam tab 0.25mg ..................... 22 alprazolam tab 0.5mg ....................... 22 alprazolam tab 1mg .......................... 22 alprazolam tab 2mg .......................... 22 ALREX ............................................ 62 altavera .......................................... 37 alum & mag hydrox-simethicone ........ 43 ALUMINUM HYDROXIDE .................... 43 aluminum hydroxide-mag carb .......... 43 aluminum hydroxide-mag trisil........... 43 amantadine hcl ................................ 28 AMBISOME ........................................ 5 amifostine crystalline ........................ 15 amikacin sulfate ................................. 4 amiloride & hydrochlorothiazide ......... 21 amiloride hcl .................................... 21 aminophylline inj .............................. 70 AMINOSYN ...................................... 55 AMINOSYN 7%/ELECTROLYTES .......... 55 AMINOSYN 8.5%/ELECTROLYTE ......... 55 AMINOSYN II ................................... 55 AMINOSYN II 8.5%/ELECTROL ........... 55 AMINOSYN M ................................... 55 AMINOSYN-HBC ............................... 55 AMINOSYN-PF 7% ............................ 55 AMINOSYN-PF INJ 10% ..................... 55 AMINOSYN-RF ................................. 55 amiodarone hcl ................................ 17 76

AMITIZA CAP 24MCG .........................47 AMITIZA CAP 8MCG ..........................47 amitriptyline hcl ................................26 amlodipine besylate ..........................19 amlodipine besylate-valsartan tab 10-160 mg ..................................................16 amlodipine besylate-valsartan tab 10-320 mg ..................................................16 amlodipine besylate-valsartan tab 5-160 mg ..................................................16 amlodipine besylate-valsartan tab 5-320 mg ..................................................16 amlodipine--benazepril hcl cap 10-20 mg ......................................................15 amlodipine-benazepril hcl cap 10-40mg ......................................................16 amlodipine-benazepril hcl cap 2.5-10 mg ......................................................15 amlodipine-benazepril hcl cap 5-10 mg 15 amlodipine-benazepril hcl cap 5-20 mg 15 amlodipine-benazepril hcl cap 5-40 mg 15 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg ................................17 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ...................................17 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ...................................17 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ..................................17 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg .....................................17 ammonium lactate ............................73 amnesteem ......................................70 amoxapine tab 100mg .......................26 amoxapine tab 150mg .......................26 amoxapine tab 25mg ........................26 amoxapine tab 50mg ........................26 amoxicillin .......................................10 amoxicillin & pot clavulanate ..............10 amphetamine-dextroamphetamine cap sr 24hr 10 mg ......................................31 amphetamine-dextroamphetamine cap sr 24hr 15 mg ......................................31 amphetamine-dextroamphetamine cap sr 24hr 20 mg ......................................31 amphetamine-dextroamphetamine cap sr 24hr 25 mg ......................................31 amphetamine-dextroamphetamine cap sr

24hr 30 mg ..................................... 31 amphetamine-dextroamphetamine cap sr 24hr 5 mg ....................................... 31 amphetamine-dextroamphetamine tab 10 mg ................................................. 31 amphetamine-dextroamphetamine tab 12.5 mg .......................................... 31 amphetamine-dextroamphetamine tab 15 mg ................................................. 32 amphetamine-dextroamphetamine tab 20 mg ................................................. 32 amphetamine-dextroamphetamine tab 30 mg ................................................. 32 amphetamine-dextroamphetamine tab 5 mg ................................................. 31 amphetamine-dextroamphetamine tab 7.5 mg............................................ 31 amphotericin b ................................... 5 ampicillin & sulbactam sodium ........... 10 ampicillin cap 250 mg ....................... 10 ampicillin cap 500 mg ....................... 10 ampicillin for susp 125 mg/5ml .......... 10 ampicillin for susp 250 mg/5ml .......... 10 ampicillin inj .................................... 10 ampicillin sodium ............................. 10 AMPYRA .......................................... 33 anagrelide hcl .................................. 51 anastrozole ..................................... 13 ANDRODERM ................................... 35 ANORO ELLIPTA ............................... 64 ANTIOXIDANT FORMULA SG .............. 59 APAP 500 .......................................... 1 APOKYN .......................................... 28 apri 28 day ...................................... 37 APRISO ........................................... 45 APTIOM........................................... 23 APTIVUS ........................................... 6 AQUA-E .......................................... 59 ARALAST NP .................................... 69 aranelle 28 ...................................... 37 ARCALYST ....................................... 52 aripiprazole odt ................................ 28 aripiprazole oral solution 1 mg/ml ...... 28 aripiprazole tabs .............................. 28 ARNUITY ELLIPTA ............................. 69 artificial tear ointment ...................... 64 ASACOL HD ..................................... 45 ascorbic acid.................................... 59 77

ASCORBIC ACID ...............................59 aspirin .............................................. 1 aspirin buffered (cal carb-mag carb-mag oxide) .............................................. 1 ASPIRIN-DIPYRIDAMOLE ...................51 ASTEPRO .........................................65 atenolol ...........................................19 atenolol & chlorthalidone ...................19 atorvastatin calcium ..........................18 atovaquone ....................................... 4 atovaquone-proguanil hcl .................... 6 ATRIPLA ........................................... 7 ATROVENT HFA ................................65 aubra 28 day ....................................37 AVASTIN ..........................................12 aviane 28.........................................37 AVITA ..............................................70 AXID AR ..........................................45 AXIRON ...........................................35 AYR NASAL DROPS............................66 azacitidine .......................................11 AZACTAM/DEX INJ 1GM ...................... 4 AZACTAM/DEX INJ 2GM ...................... 4 azathioprine .....................................52 azelastine drop 0.05% .......................63 azelastine spr 0.1% ..........................65 azelastine spr 0.15% .........................65 AZILECT ..........................................28 azithromycin ..................................... 9 AZITHROMYCIN ................................. 9 AZOPT .............................................63 AZOR 10-40MG ................................17 AZOR TAB 10-20MG ..........................17 AZOR TAB 5-20MG ............................17 AZOR TAB 5-40MG ............................17 aztreonam ........................................ 4 B b complex w/ c .................................59 B-12 DOTS.......................................59 B-12 QUICK DISSOLVE ......................59 bacitracin (ophthalmic) ......................62 bacitracin (topical) ............................70 bacitracin zinc ..................................70 bacitracin-polymyxin b ......................70 bacitracin-polymyxin b (ophth) ...........62 bacitracin-poly-neomycin-hc ..............62 baclofen ..........................................33 balsalazide disodium .........................45

balziva 28 day ................................. 37 BANZEL SUS 40MG/ML ..................... 23 BANZEL TAB 200MG ......................... 23 BANZEL TAB 400MG ......................... 23 BARACLUDE ...................................... 8 BCG VACCINE .................................. 53 b-complex vitamins .......................... 59 b-complex w/ c & calcium ................. 59 b-complex w/ c & e + zn ................... 59 b-complex w/ c & folic acid ................ 59 b-complex w/ minerals ..................... 59 bekyree 28 day ................................ 37 BELEODAQ ...................................... 12 benazepril & hydrochlorothiazide ........ 16 benazepril hcl .................................. 16 BENDEKA ........................................ 11 BENICAR ......................................... 17 BENICAR HCT 40-25MG .................... 17 BENICAR HCT TAB 20-12.5MG ........... 17 BENICAR HCT TAB 40-12.5MG ........... 17 BENLYSTA ....................................... 52 benzocaine-docusate sodium ............. 46 benzonatate .................................... 66 benzoyl peroxide .............................. 70 BENZOYL PEROXIDE ......................... 70 benzoyl peroxide-erythromycin .......... 70 benztropine mesylate ....................... 28 BENZTROPINE MESYLATE .................. 28 BEPREVE ......................................... 63 BESIVANCE ..................................... 62 beta carotene .................................. 59 betamethasone dipropionate (topical) . 72 betamethasone dipropionate augmented ...................................................... 72 betamethasone valerate .................... 72 BETASERON .................................... 33 betaxolol hcl (ophth) ........................ 63 bethanechol chloride ......................... 48 BETOPTIC-S .................................... 63 bexarotene ...................................... 14 BEXSERO ........................................ 53 bicalutamide .................................... 13 BICILLIN L-A ................................... 10 BICNU ............................................ 11 BILTRICIDE ....................................... 4 BIOSPEC DMX .................................. 66 biotin .............................................. 59 bisacodyl ......................................... 46 78

bismuth subsalicylate ........................44 bisoprolol & hydrochlorothiazide .........19 bisoprolol fumarate ...........................19 BIVIGAM ..........................................52 bleomycin sulfate ..............................11 blephamide ......................................62 blisovi 21 fe 1.5/30 28 day pack .........37 blisovi 21 fe 1/20 28 day pack ............38 B-NATAL ..........................................59 BONE DENSITY .................................57 bone meal w/ vitamin d .....................57 BOOSTRIX .......................................53 BOSULIF ..........................................13 BOUDREAUXS BUTT PASTE ................73 BREO ELLIPTA ..................................70 briellyn 28 day .................................38 BRILINTA .........................................51 BRIMONIDINE SOL 0.15% .................63 brimonidine sol 0.2% ........................63 BRINTELLIX .....................................26 BROHIST D ......................................66 bromfenac sodium (ophth) .................62 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) ......................62 bromocriptine mesylate .....................28 brompheniramine & phenyleph ...........66 brompheniramine & pseudoeph ..........66 budesonide (inhalation) .....................69 budesonide ec ..................................45 bumetanide ......................................21 buprenorphine hcl .............................34 buprenorphine hcl-naloxone hcl sl .......34 buproban .........................................34 bupropion hcl ...................................26 bupropion hcl (smoking deterrent) ......34 buspirone hcl....................................22 BUSULFEX........................................11 butorphanol tartrate ........................... 2 BYDUREON ......................................35 BYETTA ...........................................35 BYSTOLIC ........................................19 C cabergoline ......................................42 CAL/MAG .........................................57 CALCET CREAMY BITES .....................57 CALCET PETITES ...............................57 CALCI-MIX .......................................57 CALCIONATE ....................................57

calcipotriene .................................... 71 calcitonin (salmon) ........................... 42 CAL-CITRATE PLUS VITAMIN ............. 57 calcitrene oin 0.005% ....................... 71 calcitriol .......................................... 59 calcitriol inj ..................................... 59 calcitriol oral soln 1 mcg/ml ............... 59 calcium ........................................... 57 CALCIUM & MAGNESIUM ................... 57 CALCIUM 1000 + D .......................... 57 CALCIUM 500 .................................. 57 calcium acetate (phosphate binder) .... 43 calcium ascorbate ............................ 59 calcium carbonate ............................ 57 CALCIUM CARBONATE ...................... 57 calcium carbonate (antacid) .............. 43 calcium carbonate-cholecalciferol ....... 57 calcium carbonate-ergocalciferol ........ 57 calcium carbonate-mag hydrox .......... 43 calcium carbonate-simethicone .......... 43 calcium carbonate-vitamin d .............. 57 calcium carbonate-vitamin d w/ minerals ...................................................... 57 CALCIUM CITRATE............................ 57 CALCIUM CITRATE MALATE/VI ........... 57 CALCIUM CITRATE W/D .................... 57 calcium citrate-vitamin d ................... 57 calcium gluconate ............................ 57 CALCIUM GLUCONATE ...................... 57 CALCIUM GUMMIES .......................... 58 calcium lactate ................................. 58 CALCIUM LACTATE ........................... 58 calcium pantothenate ....................... 59 calcium polycarbophil ....................... 46 calcium w/ magnesium ..................... 58 calcium w/ vitamins d & k ................. 58 CALCIUM/C/D .................................. 58 CALCIUM/MAGNESIUM/VITAMIN ........ 58 CALCIUM/MAGNESIUM/ZINC ............. 58 calcium-magnesium w/ vitamin d ....... 58 calcium-magnesium-zinc ................... 58 CALMAG THINS ................................ 58 CAL-QUICK ...................................... 57 CALTRATE 600+D SOFT CHEWS ......... 58 camila 28 day .................................. 38 CANASA .......................................... 45 CANCIDAS......................................... 5 CAPASTAT SULFATE ........................... 7 79

CAPRELSA ........................................13 captopril ..........................................16 captopril & hydrochlorothiazide ...........16 CARBAGLU .......................................40 carbamazepine .................................23 CARBIDOPA/LEVODOPA/ENTACAPONE .28 carbidopa-levodopa ...........................28 carbonyl iron ....................................50 carboplatin .......................................15 carboxymethylcellulose sodium (ophth) ......................................................64 carboxymethylcellulose-glycerin .........64 CARIMUNE NANOFILTERED ................52 carteolol hcl (ophth) ..........................63 cartia xt cap 120/24hr .......................19 cartia xt cap 180/24hr .......................19 cartia xt cap 240/24hr .......................19 cartia xt cap 300/24hr .......................19 carvedilol .........................................19 castellani paint .................................71 CAYSTON .......................................... 4 cefaclor ............................................ 8 cefaclor monohydrate er ..................... 9 cefadroxil .......................................... 9 cefazolin in dextrose 1gm/50ml-5% ..... 9 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ................................ 9 cefazolin inj....................................... 9 cefazolin sodium ................................ 9 cefdinir ............................................. 9 cefepime hcl ...................................... 9 cefixime ............................................ 9 cefotaxime sodium ............................. 9 cefoxitin sodium ................................ 9 cefpodoxime proxetil .......................... 9 cefprozil............................................ 9 ceftazidime ....................................... 9 CEFTAZIDIME/DEXTROSE ................... 9 ceftriaxone sodium ............................. 9 cefuroxime axetil ............................... 9 cefuroxime sodium ............................. 9 celecoxib .......................................... 1 CELONTIN ........................................23 CENTRUM SILVER .............................59 cephalexin ........................................ 9 CERDELGA .......................................40 CEREZYME .......................................40 CERVARIX ........................................53

cetirizine hcl .................................... 65 cetirizine syrup ................................ 65 cetirizine-pseudoephedrine ................ 66 cevimeline hcl .................................. 74 CHANTIX ......................................... 34 CHANTIX CONTINUING MONTH .......... 34 CHANTIX STARTER PACK .................. 34 CHELATED CALCIUM ......................... 58 CHEMET .......................................... 37 CHLO TUSS EX ................................. 66 chlorhexidine gluconate (mouth-throat) ...................................................... 74 chloroquine phosphate ........................ 6 chlorothiazide tabs ........................... 21 chlorpheniramine & phenylephrine...... 66 chlorpheniramine & pseudoeph .......... 66 chlorpheniramine maleate ................. 65 chlorpheniramine-dm........................ 66 chlorpheniramine-phenylephrine-acetami nophen ........................................... 66 chlorpromazine hcl ........................... 28 chlorpromazine inj ............................ 28 chlorthalidone .................................. 21 cholecalciferol .................................. 59 CHOLECALCIFEROL .......................... 59 cholestyramine ................................ 18 cholestyramine light ......................... 18 choline fenofibrate............................ 18 ciclopirox ........................................ 71 ciclopirox shampoo 1% ..................... 71 cilostazol ......................................... 51 CILOXAN ......................................... 62 CIMZIA ........................................... 51 CIMZIA STARTER KIT ....................... 51 CINRYZE ......................................... 51 CIPRODEX ....................................... 74 ciprofloxacin .................................... 10 ciprofloxacin er ................................ 10 ciprofloxacin hcl (ophth).................... 62 ciprofloxacin hcl tab .......................... 10 ciprofloxacin in d5w .......................... 10 ciprofloxacin inj................................ 10 ciprofloxacn inj 400mg/40ml ............. 10 cisplatin .......................................... 15 citalopram hydrobromide .................. 26 CITRACAL CALCIUM GUMMIES ........... 58 CITRACAL PLUS HEART HEALT ........... 58 cladribine ........................................ 11 80

claravis ............................................70 clarithromycin ................................... 9 clarithromycin er................................ 9 clarithromycin for susp ....................... 9 CLARITIN .........................................65 CLARITIN REDITABS .........................65 CLASSIC PRENATAL ..........................60 clindamax ........................................70 clindamycin cap 300mg ...................... 4 clindamycin cap 75mg ........................ 4 clindamycin hcl cap 150 mg ................ 4 clindamycin phosphate ....................... 4 clindamycin phosphate (topical) ..........70 clindamycin phosphate in d5w ............. 4 clindamycin phosphate inj ................... 5 clindamycin phosphate vaginal ...........49 clindamycin sol 75mg/5ml .................. 5 CLINIMIX 2.75%/DEXTROSE 5% ........55 CLINIMIX 4.25%/DEXTROSE 25%.......55 CLINIMIX 4.25%/DEXTROSE 5% ........55 CLINIMIX 5%/DEXTROSE 15% ...........55 CLINIMIX 5%/DEXTROSE 20% ...........55 CLINIMIX 5%/DEXTROSE 25% ...........55 CLINIMIX INJ 4.25/D10 .....................55 CLINIMIX INJ 4.25/D20 .....................55 clobetasol e cream 0.05% ..................72 clobetasol propionate ........................72 clomipramine hcl ..............................26 clonazepam ......................................23 clonidine hcl .....................................21 clopidogrel bisulfate ..........................51 clorazepate dipotassium ....................23 clotrimazole .....................................74 clotrimazole (topical) .........................71 clotrimazole vaginal ..........................49 clozapine .........................................29 CLOZAPINE ......................................29 COARTEM ......................................... 6 cod liver oil ......................................60 CODITUSS DM ..................................66 colchicine w/ probenecid ..................... 1 COLCRYS .......................................... 1 colestipol hcl ....................................18 colistimethate sodium......................... 5 colocort enema 100mg ......................45 COMBIGAN.......................................63 COMBIVENT RESPIMAT ......................65 COMETRIQ .......................................14

COMPLERA ........................................ 7 COMPLETE SINUS RELIEF .................. 66 compro ........................................... 44 COMVAX ......................................... 53 CONEX COLD/ALLERGY ..................... 66 constulose ....................................... 46 CONTAC COLD/FLU MAXIMUM S ......... 66 COPAXONE INJ 40MG/ML .................. 33 CORAL CALCIUM .............................. 58 CORAL CALCIUM PLUS ...................... 58 coral calcium-magnesium w/ vitamin d 58 cormax ........................................... 72 corn dextrin ..................................... 46 cortisone acetate.............................. 41 COTELLIC ........................................ 14 COUMADIN ...................................... 49 CREON ............................................ 47 CRESTOR ........................................ 18 CRIXIVAN.......................................... 6 cromolyn sodium (mastocytosis) ........ 47 cromolyn sodium (nasal) ................... 66 cromolyn sodium (ophth) .................. 63 cromolyn sodium nebu ...................... 69 cryselle 28 ...................................... 38 CUBICIN ........................................... 5 CUVPOSA ........................................ 45 CVS CALCIUM CITRATE ..................... 58 CVS HDYROCORTISONE ACETAT ........ 72 CVS NASAL MIST ............................. 66 CVS VITAMIN C ................................ 60 cyanocobalamin ............................... 60 cyclafem 1/35 28 day ....................... 38 cyclafem 7/7/7 28 day ...................... 38 cyclophosphamide ............................ 11 CYCLOPHOSPHAMIDE ....................... 11 cycloserine ........................................ 7 cyclosporine .................................... 52 cyclosporine modified (for microemulsion) ...................................................... 52 cyred tab ........................................ 38 CYSTADANE .................................... 40 CYSTAGON ...................................... 40 cytarabine ....................................... 11 CYTO B2 ......................................... 60 D dacarbazine ..................................... 11 DAKLINZA ......................................... 8 DALIRESP ....................................... 69 81

danazol ...........................................40 dantrolene sodium ............................33 dapsone............................................ 5 DAPTACEL ........................................53 DARAPRIM ........................................ 5 daunorubicin hcl ...............................11 deblitane 28 day ...............................38 DELESTROGEN .................................41 DELTUSS DP ....................................66 delyla 28 day ...................................38 DELZICOL ........................................45 DEMSER ..........................................21 DEPEN TITRATABS ............................37 DEPO-PROVERA INJ 400/ML ...............13 desipramine hcl ................................26 DESITIN ..........................................73 desmopressin acetate spray ...............43 desmopressin acetate spray refrigerated ......................................................43 desmopressin acetate tabs .................43 desmopressin inj 4mcg/ml .................43 DESMOPRESSIN SOL 0.01%...............43 desogestrel-ethinyl estradiol (biphasic) 38 desonide ..........................................72 DESONIDE .......................................72 desoximetasone ................................72 DESOXIMETASONE ...........................72 dexamethasone ................................41 dexamethasone sodium phosphate .....41 dexamethasone sodium phosphate (ophth) ............................................62 DEXILANT ........................................48 dexrazoxane ....................................15 dextromethorphan hbr.......................66 dextromethorphan polistirex ..............66 dextromethorphan-guaifenesin ...........66 dextromethorphan-phenylephrine-aceta minophen ........................................67 DEXTROSE 10% FLEX CONTAIN..........56 DEXTROSE 10%/NACL 0.2% ..............56 DEXTROSE 10%/NACL 0.45% ............56 DEXTROSE 2.5%/NACL 0.45% ...........55 DEXTROSE 5% .................................55 DEXTROSE 5% /ELECTROLYTE ...........56 DEXTROSE 5%/LACTATED RING .........56 DEXTROSE 5%/NACL 0.2% ................56 DEXTROSE 5%/NACL 0.225% ............56 DEXTROSE 5%/NACL 0.3% ................56

DEXTROSE 5%/NACL 0.33% ............. 56 DEXTROSE 5%/NACL 0.45% ............. 56 DEXTROSE 5%/NACL 0.9% ............... 56 DEXTROSE 5%/POTASSIUM CHL ........ 56 DEXTROSE 50% ............................... 56 DEXTROSE INJ 70% ......................... 56 DIALYVITE 800/ZINC 15 ................... 60 diazepam ........................................ 23 DIAZEPAM GEL ................................ 23 diazepam inj .................................... 23 diclofenac potassium .......................... 1 diclofenac sodium............................... 2 diclofenac sodium (ophth) ................. 62 diclofenac sodium (topical) 1% gel ..... 73 dicloxacillin sodium .......................... 10 dicyclomine hcl ................................ 45 didanosine......................................... 6 DIFICID ............................................ 9 diflorasone diacetate ........................ 72 diflunisal ........................................... 2 digitek ............................................ 20 digox .............................................. 20 digoxin ........................................... 20 digoxin inj ....................................... 20 DIGOXIN SOL 50MCG/ML .................. 20 dihydroergotamine mesylate.............. 32 dilantin ........................................... 23 DILANTIN-125 SUS 125/5ML ............. 23 diltiazem cap ................................... 20 diltiazem cap 120mg/24hr ................. 20 diltiazem cap 240mg/24hr ................. 20 diltiazem cap er/12hr........................ 20 diltiazem hcl .................................... 20 diltiazem hcl coated beads ................ 20 dilt-xr cap ....................................... 20 dimenhydrinate ................................ 44 DIMETAPP LONG ACTING COUG ......... 67 DIPENTUM ....................................... 45 diphenhydramine hcl ........................ 65 diphenhydramine hcl (sleep).............. 34 diphenhydramine inj ......................... 65 diphenhydramine-acetaminophen ....... 67 diphenhydramine-acetaminophen (sleep) ...................................................... 34 diphenhydramine-phenylephrine ........ 67 diphenhydramine-phenylephrine-acetami nophen ........................................... 67 diphenoxylate w/ atropine ................. 47 82

DIPHTHERIA/TETANUS TOXOID ..........53 disopyramide phosphate ....................17 disulfiram ........................................34 divalproex sodium .............................23 docetaxel .........................................12 DOCETAXEL .....................................12 DOCETAXEL SOLN 80MG/8ML .............12 docusate calcium ..............................46 docusate sodium ...............................46 donepezil hydrochloride .....................25 dorzolamide hcl ................................63 dorzolamide hcl-timolol maleate .........63 doxazosin mesylate ...........................16 doxepin hcl ......................................26 DOXEPIN HCL (ANTIPRURITIC) ...........71 doxorubicin hcl for inj 50 mg ..............11 doxorubicin hcl liposomal inj 2mg/ml ...11 doxorubicin inj 50mg .........................11 doxy ...............................................10 doxycycline (monohydrate) ................10 doxycycline hyclate ...........................11 doxylamine succinate (sleep) .............34 doxylamine-phenylephrine-acetaminophe n ....................................................67 dronabinol .......................................44 drospirenone-ethinyl estradiol ............38 DROXIA ...........................................14 duloxetine hcl ...................................26 DURAFLU .........................................67 DURAMORPH ..................................... 2 DUREZOL .........................................62 dutasteride ......................................48 dutasteride-tamsulosin hcl .................48 E e.e.s. ............................................... 9 econazole nitrate ..............................71 ED CHLORPED ..................................65 ED CHLORPED D ...............................67 EDURANT .......................................... 6 EFFIENT...........................................51 ELDERTONIC ....................................60 ELIDEL ............................................73 ELIQUIS ..........................................49 ELITEK ............................................15 elixophyllin ......................................70 ELLA ...............................................38 ELMIRON .........................................48 EMCYT .............................................11

EMEND CAP 125MG .......................... 44 EMEND CAP 40MG ............................ 44 EMEND CAP 80MG ............................ 44 EMEND PAK 80 & 125 ....................... 44 emoquette ...................................... 38 EMSAM ........................................... 26 EMTRIVA ........................................... 6 enalapril maleate ............................. 16 enalapril maleate & hydrochlorothiazide ...................................................... 16 endocet ............................................ 2 ENGERIX-B...................................... 53 enoxaparin sodium ........................... 49 enpresse 28 day .............................. 38 ENTACAPONE................................... 28 entecavir ........................................... 8 ENTRESTO ...................................... 17 ENUCLENE....................................... 64 enulose ........................................... 46 EPIPEN 2-PAK .................................. 69 EPIPEN-JR 2-PAK ............................. 69 epirubicin hcl ................................... 11 epitol .............................................. 23 EPIVIR HBV ....................................... 8 eplerenone ...................................... 16 EPZICOM........................................... 7 EQL CALCIUM/VITAMIN D.................. 58 EQL CHILDRENS CALCIUM GUM ......... 58 EQL CHILDRENS MULTIVITAMI........... 60 EQUALACTIN ................................... 46 ergocalciferol ................................... 60 ERIVEDGE ....................................... 12 errin 28 day .................................... 38 ery pad 2% ..................................... 70 ery-tab ............................................. 9 erythrocin lactobionate ....................... 9 erythrocin stearate ............................. 9 erythromycin (acne aid) .................... 70 erythromycin (ophth) ....................... 62 erythromycin base.............................. 9 erythromycin cap 250mg ec .............. 10 erythromycin ethylsuccinate .............. 10 ESBRIET ......................................... 69 escitalopram oxalate......................... 26 esomeprazole magnesium ................. 48 esomeprazole sodium inj ................... 48 estarylla tab 0.25-35 ........................ 38 estrace ........................................... 41 83

estradiol ..........................................41 estradiol valerate ..............................41 ethambutol hcl .................................. 7 ethosuximide....................................23 etodolac ........................................... 2 etodolac er ........................................ 2 etoposide .........................................15 EURAX .............................................74 EVOTAZ ............................................ 7 EXELON PATCHES .............................25 exemestane .....................................13 EXJADE ...........................................37 EZFE FORTE .....................................60 F FABRAZYME .....................................40 falmina 28 day .................................38 famciclovir ........................................ 8 famotidine .......................................45 famotidine inj ...................................45 famotidine-calcium carbonate-magnesium hydroxide ........48 FANAPT ...........................................29 FANAPT TITRATION PACK ..................29 FARESTON .......................................13 FARXIGA ..........................................36 FARYDAK .........................................12 FASLODEX .......................................13 FAZACLO TAB 150MG ........................29 FAZACLO TAB 200MG ........................29 FEBROL ............................................ 1 felbamate .................................. 23, 24 felodipine .........................................20 fenofibrate .......................................18 fenofibrate micronized .......................18 fentanyl citrate .................................. 2 fentanyl patch 100 mcg/hr .................. 2 fentanyl patch 12 mcg/hr .................... 2 fentanyl patch 25 mcg/hr .................... 2 fentanyl patch 50 mcg/hr .................... 2 fentanyl patch 75 mcg/hr .................... 2 FENTORA .......................................... 2 ferretts ............................................50 FERRETTS IPS ..................................50 FERRIMIN 150 ..................................50 FERRIPROX ......................................37 FERROUS FUMARATE .........................50 ferrous gluconate ..............................50 FERROUS GLUCONATE.......................50

ferrous sulfate ................................. 50 FERROUS SULFATE ........................... 50 ferrous sulfate dried ......................... 50 FETZIMA ......................................... 26 FETZIMA TITRATION PACK ................ 26 FEVERALL INFANTS ............................ 1 fexofenadine hcl ............................... 65 fexofenadine-pseudoephedrine .......... 67 fiber ............................................... 46 FIBER ............................................. 46 finasteride ....................................... 48 FIRAZYR ......................................... 51 FLEBOGAMMA .................................. 52 FLEBOGAMMA DIF ............................ 52 flecainide acetate ............................. 17 FLEET BISACODYL ............................ 46 FLORASTOR KIDS............................. 44 FLOVENT DISKUS ............................. 69 FLOVENT HFA .................................. 69 fluconazole ........................................ 5 fluconazole in dextrose ....................... 5 fluconazole in nacl .............................. 6 flucytosine......................................... 6 fludarabine phosphate ...................... 12 fludrocortisone acetate ..................... 41 flunisolide (nasal) ............................. 69 fluocinolone acetonide ...................... 72 fluocinolone acetonide (otic) .............. 74 fluocinonide ..................................... 72 fluocinonide emulsified base .............. 72 FLUOROMETHOLONE ........................ 63 fluorouracil ...................................... 12 fluorouracil (topical) ......................... 73 fluoxetine cap 10mg ......................... 27 fluoxetine cap 20mg ......................... 27 fluoxetine cap 40mg ......................... 27 fluoxetine hcl ................................... 27 fluphenazine decanoate .................... 29 fluphenazine hcl ............................... 29 flurbiprofen ....................................... 2 flurbiprofen sodium .......................... 63 flutamide ........................................ 13 fluticasone propionate ....................... 72 fluticasone propionate (nasal) ............ 69 fluvoxamine maleate ........................ 23 FOLGARD ........................................ 50 folic acid ......................................... 60 FOLIC ACID ..................................... 60 84

folic acid-vitamin b6-vitamin b12 ........50 FOLITAB 500 ....................................50 fondaparinux sodium .........................49 FORTEO ...........................................42 FORTICAL ........................................42 fosinopril sodium ..............................16 fosinopril sodium & hydrochlorothiazide ......................................................16 FREAMINE HBC 6.9% ........................55 FREAMINE III ...................................55 FRESHKOTE .....................................64 FUNGOID TINCTURE..........................71 furosemide .......................................21 furosemide inj ..................................21 FUROSEMIDE INJ ..............................21 FUSILEV ..........................................15 FUZEON ............................................ 6 fyavolv tab 1 mg-5 mcg .....................41 FYCOMPA .........................................24 G gabapentin .......................................24 GABITRIL .........................................24 galantamine hydrobromide.................25 galantamine hydrobromide er .............25 GAMASTAN S/D ................................52 GAMMAGARD LIQUID ........................52 GAMMAGARD S/D .............................52 GAMMAKED ......................................52 GAMMAPLEX .....................................52 GAMUNEX-C .....................................52 ganciclovir inj 500mg ......................... 8 GARDASIL........................................53 GARDASIL 9 .....................................53 gatifloxacin (ophth) ...........................62 GATTEX ...........................................47 GAUZE PADS 2" X 2" .........................35 gaviltye-g ........................................46 gavilyte-c.........................................46 gavilyte-h ........................................46 gavilyte-n ........................................46 GAVISCON .......................................43 GAVISCON EXTRA STRENGTH R..........43 gemcitabine hcl ................................12 GEMCITABINE HCL ............................12 gemfibrozil .......................................18 generlac ..........................................46 gengraf ...........................................52 gentak .............................................62

gentamicin in saline ............................ 4 gentamicin sulfate .............................. 4 gentamicin sulfate (ophth) ................ 62 gentamicin sulfate (topical) ............... 70 GENTIAN VIOLET ............................. 71 GENVOYA .......................................... 7 GEODON ......................................... 29 GIANVI ........................................... 38 gildagia ........................................... 38 gildess 1.5/30 21 day ....................... 38 GILENYA CAP 0.5MG ......................... 33 GILOTRIF TAB 20MG......................... 14 GILOTRIF TAB 30MG......................... 14 GILOTRIF TAB 40MG......................... 14 glatopa ........................................... 33 GLEOSTINE ..................................... 11 glimepiride ...................................... 36 glip/metform tab 5-500mg ................ 36 glipizide .......................................... 36 GLIPIZIDE XL TB24 2.5MG ................ 36 GLIPIZIDE XL TB24 5MG ................... 36 glipizide-metformin hcl tab 2.5-250 mg ...................................................... 36 glipizide-metformin hcl tab 2.5-500 mg ...................................................... 36 GLUCAGEN HYPOKIT......................... 42 GLUCAGON EMERGENCY KIT ............. 42 glycerin-hypromellose-polyethylene glycol 400 ....................................... 64 glycopyrrolate .................................. 45 glycopyrrolate inj ............................. 45 GOLYTELY ....................................... 46 granisetron hcl ................................. 44 GRANIX .......................................... 50 griseofulvin microsize ......................... 6 griseofulvin ultramicrosize ................... 6 guaifenesin ...................................... 67 guaifenesin-codeine .......................... 67 guanfacine er (adhd) ........................ 32 H halobetasol propionate ...................... 72 haloperidol ...................................... 29 haloperidol decanoate ....................... 29 haloperidol lactate inj 5 mg/ml .......... 29 haloperidol lactate oral conc 2 mg/ml . 29 HARVONI .......................................... 8 HAVRIX ........................................... 53 heather ........................................... 38 85

HEPARIN SOD (PORCINE) IN D5W ......49 heparin sod inj 1000/ml .....................49 heparin sod inj 10000/ml ...................49 HEPARIN SOD INJ 2000/ML ................49 heparin sod inj 20000/ml ...................49 HEPARIN SOD INJ 2500/ML ................49 heparin sod inj 5000/ml .....................49 HEPARIN SODIUM/D5W .....................50 HEPARIN SODIUM/NACL 0.45% ..........50 HEPATAMINE ....................................55 HERCEPTIN ......................................12 HETLIOZ ..........................................32 HEXALEN .........................................11 HIBERIX ..........................................53 HONEY BEARS ..................................60 HONEY BEARS W/IRON AND ZI ..........60 HUMIRA ...........................................51 HUMIRA KIT 40MG/0.8 ......................51 HUMIRA PEDIATRIC CROHNS .............52 HUMIRA PEN ....................................52 HUMIRA PEN-CROHNS DISEASE .........52 HUMIRA PEN-PSORIASIS STAR ...........52 HUMULIN R U-500 VIAL (CONCENTRATE) ......................................................35 hydralazine hcl .................................21 hydrochlorothiazide ...........................21 HYDROCIL INSTANT ..........................46 hydroco/apap tab 10-325mg ............... 3 hydroco/apap tab 5-325mg ................. 3 hydroco/apap tab 7.5-325 .................. 3 hydrocodone-acetaminophen 7.5-325 mg/15ml .......................................... 3 hydrocodone-ibuprofen tab 7.5-200 mg 3 hydrocortisone .................................41 HYDROCORTISONE (INTRARECTAL) ....45 hydrocortisone (topical) ......... 71, 72, 73 hydrocortisone acetate-aloe vera ........73 hydrocortisone butyrate .....................73 hydrocortisone valerate .....................73 hydrocortisone-aloe vera ...................73 hydromorphon inj 10mg/ml ................. 3 hydromorphone hcl ............................ 3 hydroxocobalamin .............................60 hydroxychloroquine sulfate ................52 hydroxyurea .....................................14 hydroxyzine hcl ................................65 hydroxyzine pamoate ........................65 HYPOTEARS .....................................64

hypromellose (gonioscopic) ............... 64 hypromellose (ophth) ....................... 64 I ibandronate tab 150mg ..................... 37 IBRANCE ......................................... 12 ibuprofen ...................................... 1, 2 IBUPROFEN ....................................... 1 ibuprofen-diphenhydramine citrate ..... 34 ICAPS LUTEIN/ZEAXANTHIN F ........... 60 ICLUSIG .......................................... 14 idarubicin hcl ................................... 11 IFEX INJ 3GM .................................. 11 ifosfamide inj 1gm............................ 11 ifosfamide inj 1gm/20ml ................... 11 IFOSFAMIDE INJ 3GM ....................... 11 ifosfamide inj 3gm/60ml ................... 11 ILEVRO ........................................... 63 ilotycin ............................................ 62 imatinib mesylate ............................. 14 IMBRUVICA CAP 140MG .................... 14 imipenem-cilastatin ............................ 5 imipramine hcl ................................. 27 imiquimod ....................................... 73 IMOVAX RABIES (H.D.C.V.) ............... 53 INCRELEX ....................................... 42 INCRUSE ELLIPTA ............................ 65 indapamide ..................................... 21 INFANRIX ........................................ 53 INLYTA ........................................... 14 INSULIN PEN NEEDLE ....................... 35 INSULIN SAFETY NEEDLES ................ 35 INSULIN SYRINGE ............................ 35 INTEGRA ......................................... 50 INTELENCE ........................................ 6 INTRALIPID INJ 20% ........................ 55 INTRALIPID INJ 30% ........................ 55 INTRON-A INJ 10MU ......................... 52 INTRON-A INJ 18MU ......................... 52 INTRON-A INJ 25MU ......................... 52 INTRON-A INJ 50MU ......................... 52 introvale 91 day ............................... 38 INVANZ ............................................ 5 INVEGA........................................... 29 INVEGA SUST INJ 117 MG/0.75 ML .... 29 INVEGA SUST INJ 156MG/ML ............. 29 INVEGA SUST INJ 234 MG/1.5 ML ...... 29 INVEGA SUST INJ 39 MG/0.25 ML ...... 29 INVEGA SUST INJ 78 MG/0.5 ML ........ 29 86

INVEGA TRINZA................................29 INVIRASE ......................................... 6 INVOKAMET TAB 150-1000 ................36 INVOKAMET TAB 150-500 ..................36 INVOKAMET TAB 50-1000 ..................36 INVOKAMET TAB 50-500MG ...............36 INVOKANA .......................................36 IONOSOL-B/DEXTROSE 5% ...............56 IONOSOL-MB/DEXTROSE 5% .............56 IPOL INACTIVATED IPV......................53 ipratropium bromide .........................65 ipratropium bromide (nasal) ...............65 ipratropium-albuterol nebu ................65 irbesartan ........................................17 irbesartan-hydrochlorothiazide ...........17 IRESSA ............................................14 irinotecan inj 100/5ml .......................15 irinotecan inj 40mg/2ml.....................15 irinotecan inj 500mg/25ml .................15 IRON ...............................................50 IRON CHEWS PEDIATRIC ...................50 IRON UP ..........................................50 iron w/ vitamins ...............................60 iron-vitamin c ...................................51 iron-vitamin c-vitamin b12-folic acid ...51 ISENTRESS ....................................... 6 ISOLYTE P........................................56 ISOLYTE S .......................................56 isoniazid ........................................... 7 isoniazid inj 100 mg/ml ...................... 7 isoniazid syp 50mg/5ml ...................... 7 ISOPTO TEARS .................................64 isosorb mononitrate tab .....................21 isosorbide dinitrate ...........................21 isosorbide dinitrate er ........................21 isosorbide mononitrate er ..................21 isradipine .........................................20 ISTALOL ..........................................63 ISTODAX .........................................12 itraconazole ...................................... 6 ivermectin......................................... 5 IXIARO ............................................53 J JAKAFI ............................................14 jantoven ..........................................50 JANUMET .........................................36 JANUMET XR TAB 100-1000 ...............36 JANUMET XR TAB 50-1000 .................36

JANUMET XR TAB 50-500MG.............. 36 JANUVIA ......................................... 36 JENTADUETO ................................... 36 jinteli .............................................. 41 J-MAX ............................................. 67 JOLESSA TAB 0.15-0.03 MG .............. 38 JOLIVETTE....................................... 38 J-TAN D PD ..................................... 67 J-TAN PD......................................... 65 juleber 28 day ................................. 38 junel 1.5/30 21 day .......................... 38 junel 1/20 21 day............................. 38 junel fe 1.5/30 28 day ...................... 38 junel fe 1/20 28 day ......................... 38 JUXTAPID ........................................ 18 K KADCYLA ........................................ 12 KALETRA SOL .................................... 7 KALETRA TAB 100-25MG ..................... 7 KALETRA TAB 200-50MG ..................... 7 KALYDECO ...................................... 69 kariva 28 day .................................. 38 KCL 0.075%/D5W/NACL 0.45% ......... 56 KCL 0.15%/D5W/NACL 0.9% ............. 56 KCL 0.3%/D5W/NACL 0.45% ............. 56 KCL 0.3%/D5W/NACL 0.9% .............. 56 KCL IN NACL INJ .15-0.45 ................. 56 KCL/D5W INJ 0.3% .......................... 56 KCL/D5W/NACL INJ .15/.33% ............ 56 KCL/D5W/NACL INJ .15/.45% ............ 56 KCL/D5W/NACL INJ 0.22%/0.45% ..... 56 KCL/NACL INJ 0.15%-0.9% ............... 56 KCL/NACL INJ 0.3-0.9....................... 56 KCL0.15%/D5W/NACL0.2% ............... 56 KCL0.15%/D5W/NACL0.225% ........... 56 kelnor 1/35 28 day ........................... 38 ketoconazole ..................................... 6 ketoconazole cream .......................... 71 ketoconazole shampoo ...................... 71 ketoprofen ........................................ 2 ketorolac tromethamine (ophth) ........ 63 ketotifen fumarate (ophth) ................ 63 KEYTRUDA ...................................... 12 kimidess 28 day ............................... 38 KINRIX ........................................... 53 kionex ............................................ 37 KLOR-CON 10 .................................. 54 KLOR-CON 8 .................................... 54 87

klor-con m10....................................54 klor-con m15....................................54 klor-con m20....................................54 klor-con pow 20meq..........................54 klor-con spr cap 10meq .....................54 klor-con spr cap 8meq .......................54 KONSYL ...........................................46 KONSYL-D .......................................46 KORLYM...........................................42 KPN PRENATAL .................................60 KUVAN ............................................40 KYNAMRO ........................................18 L labetalol hcl .....................................19 LACTATED RINGER'S INJ ...................56 lactobacillus .....................................44 lactobacillus rhamnosus (gg) ..............44 lactulose ..........................................46 lactulose (encephalopathy) ................46 LAMISIL ADVANCED ..........................71 lamivudine ........................................ 6 lamivudine (hbv) ............................... 8 lamivudine-zidovudine ........................ 7 lamotrigine ......................................24 lansoprazole .....................................48 LANTUS ...........................................35 LANTUS SOLOSTAR ...........................35 larin 1.5/30 ......................................38 larin 1/20.........................................38 larin fe 1.5/30 ..................................38 larin fe 1/20 .....................................38 LASTACAFT ......................................63 latanoprost ......................................63 LATUDA ...........................................29 LEENA .............................................38 leflunomide ......................................52 LENVIMA 10MG DAILY DOSE ..............14 LENVIMA 14MG DAILY DOSE ..............14 LENVIMA 20MG DAILY DOSE ..............14 LENVIMA 24MG DAILY DOSE ..............14 lessina 28 day ..................................38 LETAIRIS .........................................22 letrozole ..........................................13 leucovorin calcium ............................15 leucovorin calcium for inj 500 mg .......15 LEUKERAN .......................................11 LEUKINE ..........................................50 leuprolide acetate .............................13

levalbuterol conc 1.25mg/0.5ml ......... 66 LEVEMIR ......................................... 35 LEVEMIR FLEXTOUCH ....................... 35 levetiracetam................................... 24 LEVETIRACETAM IV .......................... 24 levetiracetam oral soln 100 mg/ml ..... 24 levobunolol hcl ................................. 63 levocarnitine (metabolic modifiers) ..... 40 levocetirizine dihydrochloride ............. 65 levofloxacin ..................................... 10 levofloxacin in d5w ........................... 10 levofloxacin inj 25mg/ml ................... 10 levofloxacin oral soln 25 mg/ml.......... 10 levoleucovorin calcium ...................... 15 levonest 28 day ............................... 38 levonor/ethi tab ............................... 38 levonorgestrel & eth estradiol ............ 38 levonorgestrel (emergency oc) ........... 39 levonorgestrel-ethinyl estradiol (91-day) ...................................................... 39 levora 0.15/30 28 day ...................... 39 levothyroxine sodium........................ 43 LEVOXYL ......................................... 43 LEXIVA ............................................. 6 lidocaine ......................................... 73 lidocaine hcl .................................... 73 lidocaine hcl (local anesth.) ................. 4 lidocaine hcl (mouth-throat) .............. 74 lidocaine inj 0.5% .............................. 4 lidocaine inj 1% ................................. 4 lidocaine inj 1.5% .............................. 4 lidocaine inj 2% ................................. 4 lidocaine oint 5% ............................. 73 lidocaine-prilocaine ........................... 73 linezolid ............................................ 5 LINEZOLID ........................................ 5 LINEZOLID IN SODIUM CHLORIDE ....... 5 LINZESS ......................................... 47 liothyronine sodium .......................... 43 LIQUID CALCIUM WITH D3 MA ........... 58 lisinopril .......................................... 16 lisinopril & hydrochlorothiazide........... 16 lithium carbonate ............................. 33 lithium carbonate er ......................... 33 LITHIUM SOLN 8MEQ/5ML ................. 33 LOCALNESIUM ................................. 58 LOCALNESIUM-C .............................. 58 LODRANE D ..................................... 67 88

LOHIST-D ........................................67 lokara..............................................73 LONSURF .........................................14 loperamide hcl ............................ 44, 47 loratadine ........................................65 loratadine & pseudoephedrine ............67 lorazepam ........................................23 lorcet hd tab 10-325mg ...................... 3 lorcet plus tab 7.5-325 ....................... 3 lorcet tab 5-325mg ............................ 3 lortab tab 10-325mg .......................... 3 lortab tab 5-325mg ............................ 3 lortab tab 7.5-325.............................. 3 loryna 28 day ...................................39 losartan potassium ............................17 losartan-hydrochlorothiazide ..............17 LOTEMAX .........................................63 LOTRIMIN ULTRA ..............................71 lovastatin .........................................18 low-ogestrel .....................................39 loxapine succinate ............................29 LUMIGAN .........................................63 LUMITENE ........................................60 LUMIZYME .......................................40 LUPRON DEPOT ................................13 LUPRON DEPOT INJ 11.25 MG ............13 LUPRON DEP-PED INJ 11.25MG ..........13 LUPRON DEP-PED INJ 15MG ...............13 LUPRON DEP-PED INJ 30MG (3-MONTH) ......................................................13 LUPRON DEP-PED INJ 7.5MG ..............13 lutera 28 day....................................39 LYNPARZA........................................12 LYRICA ............................................24 LYSODREN .......................................13 lyza .................................................39 M MAG-AL ...........................................43 MAGINEX .........................................58 MAGNEBIND 300 ..............................58 magnesium ......................................58 MAGNESIUM.....................................58 magnesium chloride ..........................58 magnesium chloride-calcium ..............58 magnesium citrate ............................46 MAGNESIUM CITRATE .......................58 MAGNESIUM ELEMENTAL ...................58 magnesium hydroxide .......................46

magnesium oxide ............................. 43 MAGNESIUM OXIDE .......................... 43 magnesium oxide (laxative) .............. 46 magnesium oxide (mg supplement) .... 58 magnesium sulfate ........................... 54 MAGNESIUM SULFATE ...................... 54 magnesium sulfate (laxative) ............. 46 MAGNESIUM SULFATE IN D5W........... 54 MAG-TAB SR.................................... 58 malathion ........................................ 74 maprotiline hcl ................................. 27 marlissa 28 day ............................... 39 MARPLAN TAB 10MG ......................... 27 MATULANE ...................................... 14 MAXIDEX ........................................ 63 meclizine hcl .................................... 44 medroxyprogesterone acetate 150 mg/ml ...................................................... 39 medroxyprogesterone acetate tab ...... 43 mefloquine hcl ................................... 6 megestrol ac sus 40mg/ml ................ 13 megestrol ac tab 20mg ..................... 13 megestrol ac tab 40mg ..................... 13 MEGESTROL SUS 625MG/5ML ............ 13 MEKINIST ....................................... 14 meloxicam ........................................ 2 MELOXICAM ...................................... 2 melphalan hcl .................................. 11 memantine hcl ................................. 25 MENACTRA ...................................... 53 M-END DMX ..................................... 67 MENOMUNE-A/C/Y/W-135 ................. 53 MENVEO ......................................... 53 MEPHYTON ...................................... 60 mercaptopurine ............................... 12 meropenem ....................................... 5 mesalamine enema .......................... 45 mesalamine w/ cleanser .................... 45 mesna ............................................ 15 MESNEX .......................................... 15 metadate er tab 20mg ...................... 32 METAMUCIL ..................................... 46 METAMUCIL MULTIHEALTH FIB .......... 46 METAMUCIL SMOOTH TEXTURE .......... 46 metformin er ................................... 36 metformin hcl .................................. 36 methadone hcl ................................... 3 methazolamide ................................ 21 89

methenamine hippurate ...................... 5 methimazole ....................................43 methotrexate sodium ........................12 METHOTREXATE SODIUM ...................12 methotrexate sodium inj ....................12 methotrexate sodium tabs .................52 methyclothiazide...............................21 methylcellulose (laxative) ..................46 methylergonovine maleate .................42 methylphenidate hcl ..........................32 methylphenidate hcl oral soln .............32 methylpr ace inj 40mg/ml ..................41 methylpr ace inj 80mg/ml ..................41 methylpr ss inj 125mg .......................41 methylpr ss inj 1gm ..........................41 methylpr ss inj 40mg ........................41 methylpred pak 4mg .........................41 methylpred tab 16mg ........................41 methylpred tab 32mg ........................41 methylpred tab 4mg ..........................41 methylpred tab 8mg ..........................41 metipranolol .....................................63 metoclopramide hcl ...........................44 metoclopramide inj ...........................44 metolazone ......................................21 metoprolol & hctz tab 100-25mg.........19 metoprolol & hctz tab 100-50mg.........19 metoprolol & hctz tab 50-25mg ..........19 metoprolol succinate .........................19 metoprolol tartrate ............................19 metronidazole ................................... 5 metronidazole (topical) ......................73 metronidazole gel 0.75% ...................73 metronidazole in nacl ......................... 5 metronidazole vaginal .......................49 mexiletine hcl ...................................17 MEXSANA ........................................73 MIACALCIN ......................................42 miconazole nitrate (topical) ................71 miconazole nitrate vaginal .................49 MICROGESTIN 1.5/30........................39 MICROGESTIN 1/20 ..........................39 MICROGESTIN FE 1.5/30 ...................39 MICROGESTIN FE 1/20 ......................39 midodrine hcl ...................................21 MILK OF MAGNESIA CONCENTR ..........46 mineral oil .......................................46 MINERAL OIL....................................46

minitran .......................................... 21 minocycline hcl ................................ 11 minoxidil ......................................... 21 mirtazapine ..................................... 27 misoprostol ..................................... 47 MISSION PRENATAL ......................... 60 MISSION PRENATAL HP..................... 60 mitomycin ....................................... 11 mitoxantrone hcl .............................. 14 M-M-R II ......................................... 53 moderiba 800 dose pack ..................... 8 moderiba pak 1000/day ...................... 8 MODERIBA PAK 1200/DAY ................... 8 moderiba pak 600/day ........................ 8 moderiba tab 200mg .......................... 8 moexipril hcl .................................... 16 moexipril-hydrochlorothiazide ............ 16 molindone hcl .................................. 29 mometasone furoate ........................ 73 mometasone furoate (nasal) .............. 69 mono-linyah tab 0.25-35................... 39 MONONESSA ................................... 39 montelukast sodium ......................... 69 morphine ext-rel tab........................... 3 MORPHINE SUL INJ 10MG/ML .............. 3 MORPHINE SUL INJ 15MG/ML .............. 3 MORPHINE SUL INJ 1MG/ML ................ 3 MORPHINE SUL INJ 4MG/ML ................ 3 morphine sulfate ................................ 3 MORPHINE SULFATE ........................... 3 morphine sulfate beads ....................... 3 morphine sulfate cap 100mg er ............ 3 MORPHINE SULFATE ORAL SOL ............ 3 MOVANTIK ...................................... 47 MOVIPREP ....................................... 46 MOXEZA.......................................... 62 MOZOBIL ........................................ 50 MUCINEX COUGH FOR KIDS .............. 67 MUCINEX D ..................................... 67 MUCINEX D MAXIMUM STRENGT ........ 67 MUCINEX FOR KIDS ......................... 67 MUCINEX MAXIMUM STRENGTH ......... 67 MULTAQ .......................................... 18 MULTI-DELYN/IRON .......................... 60 multiple vitamins w/ iron ................... 60 multiple vitamins w/ minerals ............ 60 mupirocin ........................................ 70 MURO 128 ....................................... 64 90

MUSTARGEN ....................................11 MYCAMINE ........................................ 6 mycophenolate mofetil ................ 52, 53 mycophenolate sodium ......................53 MYKIDZ IRON ...................................60 MYKIDZ IRON 10 ..............................51 myorisan .........................................70 MYOZYME ........................................40 MYRBETRIQ......................................48 myzilra ............................................39 N nabumetone ...................................... 2 nadolol ............................................19 nafcillin sodium ................................10 NAGLAZYME .....................................41 nalbuphine hcl ................................... 2 naloxone hcl .....................................34 naltrexone hcl ..................................34 NAMENDA XR ...................................25 NAMENDA XR TITRATION PACK ..........25 NAMZARIC .......................................25 naphazoline 0.1% .............................64 NAPHAZOLINE W/ PHENIRAMINE ........63 naphazoline-glycerin .........................63 naproxen .......................................... 2 naproxen sodium ............................1, 2 NAPROXEN SODIUM ........................... 1 naratriptan hcl ..................................32 NASAL DECONGESTANT .....................67 NASCOBAL .......................................60 NASONEX ........................................69 NASOPEN PE ....................................67 NATACYN .........................................62 nateglinide .......................................37 NATPARA .........................................43 NEBUPENT ........................................ 5 necon 0.5/35 28 day .........................39 necon 1/35 28 day ............................39 necon 10/11 28 day ..........................39 NECON 7/7/7 ...................................39 NECON TAB 1/50-28 .........................39 nefazodone hcl .................................27 neomycin sulfate ............................... 4 neomycin-bacitracin zn-polymyxin ......62 neomycin-bacitracin-polymyxin ..........70 neomycin-polymy-dexameth ..............62 neomycin-polymyxin-gramicidin .........62 neomycin-polymyxin-hc (ophth) .........62

neomycin-polymyxin-hc (otic)............ 74 NEORAL .......................................... 53 NEPHRAMINE ................................... 55 NEPHRONEX .................................... 60 NEUMEGA ....................................... 50 NEUPOGEN ...................................... 50 NEUPRO .......................................... 28 nevirapine ......................................... 6 NEVIRAPINE ...................................... 6 NEXAFED SINUS PRESSURE + ........... 67 NEXAVAR ........................................ 14 NEXIUM CAP 20MG ........................... 48 NEXIUM CAP 40MG ........................... 48 NEXIUM GRA 10MG DR ..................... 48 NEXIUM GRA 2.5MG DR .................... 48 NEXIUM GRA 20MG DR ..................... 48 NEXIUM GRA 40MG DR ..................... 48 NEXIUM GRA 5MG DR ....................... 48 niacin ............................................. 60 niacin er (antihyperlipidemic) ............ 18 NIACIN TR....................................... 60 niacinamide ..................................... 60 niacor ............................................. 18 nicardipine hcl ................................. 20 nicotine ........................................... 34 nicotine polacrilex ............................ 34 NICOTINE POLACRILEX ..................... 34 NICOTINE TRANSDERMAL SYST ......... 34 NICOTROL INHALER ......................... 34 NICOTROL NS .................................. 34 nifedical .......................................... 20 nifedipine ........................................ 20 nifedipine er .................................... 20 nikki 28 day .................................... 39 NILANDRON .................................... 13 nimodipine ...................................... 20 NINLARO ......................................... 12 NIPENT ........................................... 12 nitro-bid.......................................... 21 NITRO-DUR DIS 0.3MG/HR ................ 22 NITRO-DUR DIS 0.8MG/HR ................ 22 nitrofurantoin macrocrystal ................. 5 nitrofurantoin monohyd macro ............. 5 nitroglycerin .................................... 22 NITROSTAT ..................................... 22 NORA-BE TAB .................................. 39 NORDITROPIN FLEXPRO .................... 42 NOREL AD ....................................... 67 91

norethindrone (contraceptive) ............39 norethindrone acetate .......................43 norethindrone acetate-ethinyl estradiol 41 norgest/ethi tab 0.25/35....................39 norgestimate-ethinyl estradiol (triphasic) ......................................................39 norlyroc 28 day ................................39 NORMOSOL-M IN D5W ......................56 NORMOSOL-R ...................................56 NORMOSOL-R IN D5W .......................56 NORPACE CR ....................................18 nortrel 0.5/35 28 day ........................39 nortrel 1/35 21 day ...........................39 nortrel 1/35 28 day ...........................39 nortrel 7/7/7 28 day..........................39 nortriptyline hcl ................................27 NORVIR ............................................ 6 NOVAFERRUM 125 ............................51 NOVAFERRUM PEDIATRIC DROP .........51 NOVOLIN 70/30 ................................35 NOVOLIN N ......................................35 NOVOLIN R ......................................35 NOVOLOG ........................................35 NOVOLOG FLEXPEN ...........................35 NOVOLOG MIX 70/30 ........................35 NOVOLOG MIX 70/30 PREFILL ............35 NOVOLOG PENFILL............................35 NOXAFIL ........................................... 6 NUEDEXTA .......................................33 NULOJIX ..........................................53 NULYTELY/FLAVOR PACKS .................47 NUTRILIPID INJ 20%.........................55 NUTRISOURCE FIBER ........................47 NUVARING .......................................39 NUVIGIL ..........................................34 nyamyc ...........................................71 NYMALIZE ........................................20 nystatin ............................................ 6 nystatin (mouth-throat) .....................74 nystatin (topical) ..............................71 nystop .............................................71 O OCELLA TAB 3-0.03MG ......................39 OCTAGAM ........................................52 octreotide acetate .............................42 ODOMZO .........................................14 OFEV ...............................................69 ofloxacin (ophth) ..............................62

ofloxacin (otic) ................................. 75 olanzapine ....................................... 30 olopatadine hcl (nasal) ...................... 65 omega-3-acid ethyl esters ................. 18 omeprazole ..................................... 48 OMEPRAZOLE .................................. 48 omeprazole-sodium bicarbonate ......... 48 ondansetron hcl ............................... 44 ondansetron hcl inj ........................... 44 ondansetron hcl oral soln .................. 44 ondansetron odt ............................... 44 ONFI .............................................. 24 ophthalmic irrigation solution ............. 64 OPSUMIT ........................................ 22 oral electrolytes ............................... 54 ORFADIN......................................... 41 ORKAMBI ........................................ 69 orsythia 28 day ................................ 39 OSTEO-PORETICAL ........................... 58 oxacillin sodium ............................... 10 oxaliplatin ....................................... 15 oxandrolone .................................... 35 oxcarbazepine ................................. 24 oxybutynin chloride ..................... 48, 49 oxycodone hcl .................................... 3 OXYCODONE HCL ............................... 3 oxycodone w/ acetaminophen 10-325mg ........................................................ 4 oxycodone w/ acetaminophen 2.5-325mg ........................................................ 4 oxycodone w/ acetaminophen 5-325mg 4 oxycodone w/ acetaminophen 7.5-325mg ........................................................ 4 oxymetazoline hcl ............................ 67 oyster shell ..................................... 58 P pacerone ......................................... 18 paclitaxel ........................................ 12 paliperidone .................................... 30 pamidronate disodium ...................... 37 PANOXYL-4 CREAMY WASH ............... 71 PANRETIN ....................................... 73 pantoprazole sodium tbec ................. 48 paricalcitol....................................... 60 paroex sol 0.12% ............................. 74 paromomycin sulfate .......................... 4 paroxetine hcl tabs ........................... 27 PARVA-CAL...................................... 58 92

paser d/r .......................................... 7 PATADAY .........................................63 PAXIL ..............................................27 PAZEO .............................................63 PEDIA-LAX .......................................47 PEDIARIX.........................................53 pediatric multiple vitamin w/ c ............60 pediatric multiple vitamin w/ c & fa .....60 pediatric multiple vitamin w/ extra c & fa ......................................................61 pediatric multiple vitamin w/ minerals & c ......................................................61 pediatric multiple vitamins .................61 pediatric multiple vitamins w/ iron ......61 pediatric vitamins adc........................61 PEDVAX HIB .....................................53 PEG 3350/ELECTROLYTES ..................47 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE...................47 peg 3350-potassium chloride-sod bicarbonate-sod chloride ....................47 PEGANONE .......................................24 PEGASYS .......................................... 8 PEGASYS PROCLICK ........................... 8 PEGINTRON ...................................... 8 PEG-INTRON REDIPEN ........................ 8 PENICILLIN G POT IN DEXTROSE ........10 penicillin g procaine ..........................10 penicillin g sodium ............................10 penicillin v potassium ........................10 penicilln gk inj 20mu .........................10 penicilln gk inj 5mu ...........................10 PENTACEL ........................................53 PENTAM 300 ..................................... 5 pentoxifylline....................................51 PEPCID AC .......................................45 PERFOROMIST ..................................66 perindopril erbumine .........................16 periogard .........................................74 permethrin .......................................74 permethrin & pyrethrins-piperonyl butoxide ..........................................74 perphenazine ...................................30 PERRY PRENATAL ..............................61 phenadoz .........................................44 PHENAGIL ........................................67 phenelzine sulfate .............................27 phenergan .......................................44

phenobarbital .................................. 24 phenobarbital sodium ....................... 24 PHENOBARBITAL SODIUM ................. 24 phenylephrine hcl ............................. 67 phenylephrine hcl (oral) .................... 67 phenylephrine w/ acetaminophen ....... 67 phenylephrine w/ dm-gg ................... 67 phenylephrine-acetaminophen-guaifenesi n .................................................... 67 phenylephrine-brompheniramine-dm .. 67 phenylephrine-chlorphen-dm ............. 67 phenylephrine-chlorpheniramine-dm w/ apap ............................................... 67 phenylephrine-dm ............................ 67 phenylephrine-dm-gg w/ apap ........... 68 phenylephrine-doxylamine-dextromethor phan-acetaminophen ........................ 68 phenylephrine-guaifenesin................. 68 phenytek ......................................... 24 phenytoin ........................................ 24 phenytoin sodium ............................. 24 phenytoin sodium extended ............... 24 philith ............................................. 39 PHOS-NAK POWDER CONCENTRA....... 58 PHOSPHOLINE IODIDE ...................... 63 phytonadione ................................... 61 PILOCARPINE HCL ............................ 63 pilocarpine hcl (oral) ......................... 74 PILOCARPINE HCL (ORAL) ................. 74 pimozide ......................................... 30 pimtrea pack ................................... 39 pindolol ........................................... 19 pioglitazone hcl ................................ 37 piperacillin sodium-tazobactam sodium 10 pirmella 1/35 28 day ........................ 40 piroxicam .......................................... 2 PLASMA-LYTE A ............................... 56 PLASMA-LYTE-148 ............................ 56 PLASMA-LYTE-56/D5W...................... 56 podofilox ......................................... 73 polyethylene glycol 3350 ................... 47 polyethylene glycol-propylene glycol (ophth) ........................................... 64 polymyxin b-trimethoprim ................. 62 polysaccharide iron complex .............. 51 polyvinyl alcohol .............................. 64 polyvinyl alcohol-povidone (ophth) ..... 64 POMALYST CAP 1MG ......................... 14 93

POMALYST CAP 2MG .........................14 POMALYST CAP 3MG .........................14 POMALYST CAP 4MG .........................14 portia 28 day....................................40 pot chloride inj 2meq/ml ....................56 potassium chloride ............................54 POTASSIUM CHLORIDE ................ 54, 57 potassium chloride in nacl ..................57 potassium chloride microencapsulated crystals cr ........................................54 POTASSIUM CHLORIDE TAB CR 10 MEQ ......................................................55 POTASSIUM CITRATE (ALKALINIZER) ..48 POTIGA ...........................................24 povidone-iodine vaginal .....................49 PRADAXA .........................................50 PRALUENT........................................18 pramipexole dihydrochloride...............28 pravastatin sodium ...........................18 prazosin hcl......................................16 pred sod pho sol 5mg/5ml .................41 PREDNISOLONE ACETATE (OPHTH) .....63 prednisolone sodium phosphate (ophth) ......................................................63 prednisolone sol 15mg/5ml ................41 prednisolone sol 25mg/5ml ................41 prednisolone syp 15mg/5ml ...............41 prednisone con 5mg/ml .....................42 prednisone pak 10mg ........................42 prednisone pak 5mg ..........................42 prednisone sol 5mg/5ml ....................42 prednisone tab 10mg ........................42 prednisone tab 1mg ..........................42 prednisone tab 2.5mg .......................42 prednisone tab 20mg ........................42 prednisone tab 50mg ........................42 prednisone tab 5mg ..........................42 premasol sol 10% .............................55 premasol sol 6% ...............................55 PRENATAL ........................................61 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC) .................................61 PRETZ .............................................68 prevalite ..........................................18 previfem 28 day ...............................40 PREZCOBIX ....................................... 7 PREZISTA ......................................... 6 PRIFTIN ............................................ 7

PRILOSEC OTC................................. 48 PRIMAQUINE PHOSPHATE ................... 6 primidone........................................ 24 PRISTIQ .......................................... 27 PRIVIGEN ........................................ 52 probenecid ........................................ 1 PROCALAMINE ................................. 55 PRO-CHLO ....................................... 68 prochlorperazine inj .......................... 44 prochlorperazine maleate .................. 44 prochlorperazine supp....................... 44 PROCRIT ......................................... 50 procto-pak ...................................... 71 proctosol hc cre 2.5% ....................... 71 proctozone hc .................................. 71 PROFE ............................................ 51 PROGLYCEM SUS 50MG/ML ............... 42 PROGRAF ........................................ 53 PROLASTIN-C .................................. 69 PROLENSA....................................... 64 PROLEUKIN ..................................... 12 PROLIA ........................................... 42 PROMACTA ...................................... 51 promethazine hcl ............................. 44 promethegan ................................... 45 propafenone hcl ............................... 18 propafenone hcl 12hr ........................ 18 proparacaine hcl .............................. 64 propranolol & hydrochlorothiazide ...... 19 propranolol cap er ............................ 19 propranolol hcl ................................. 19 propylene glycol-glycerin................... 64 propylthiouracil ................................ 43 PROQUAD ....................................... 54 PROSOL .......................................... 55 protriptyline hcl................................ 27 PRUDOXIN CRE 5% .......................... 71 pseudoephed-bromphen-dm .............. 68 pseudoephed-doxyl-dm w/apap ......... 68 pseudoephedrine hcl ......................... 68 pseudoephedrine w/ dm-gg ............... 68 pseudoephedrine-chlorphen-dm ......... 68 pseudoephedrine-dexchlorpheniramine-c hlophedianol .................................... 68 pseudoephedrine-guaifenesin ............ 68 psyllium .......................................... 47 PULMICORT FLEXHALER .................... 69 PULMOZYME .................................... 69 94

PURIXAN .........................................12 pyrazinamide .................................... 7 PYRETHINS/PIPERONYL BUTO ............74 pyrethrins-piperonyl butoxide .............74 pyridostigmine bromide .....................33 pyridoxine hcl ...................................61 pyrilamine maleate-phenylephrine hcl tannate ...........................................68 pyrilamine-phenylephrine ..................68 Q QUADRACEL .....................................54 quasense 91 day...............................40 quetiapine fumarate ..........................30 quinapril hcl .....................................16 quinapril-hydrochlorothiazide .............16 quinidine gluconate ...........................18 quinidine sulfate ...............................18 quinine sulfate ................................... 6 R RA CALAMINE ...................................73 RA CALCIUM/BORON .........................58 RA OYSTER SHELL CALCIUM/V ...........58 RA PROBIOTIC COMPLEX ...................44 RABAVERT .......................................54 raloxifene hcl ...................................42 ramipril ...........................................16 RANEXA ...........................................21 ranitidine hcl ....................................45 ranitidine hcl inj ................................45 ranitidine syrup ................................45 RAPAMUNE .......................................53 RAVICTI ..........................................41 REBETOL SOLN .................................. 8 reclipsen 28 day ...............................40 RECOMBIVAX HB ..............................54 REFRESH CELLUVISC.........................64 REFRESH OPTIVE ADVANCED .............64 REGRANEX .......................................74 RELENZA DISKHALER ......................... 8 RELISTOR ........................................47 RELPAX ...........................................33 REMICADE .......................................52 REMODULIN .....................................22 RENVELA PAK 0.8GM .........................43 RENVELA PAK 2.4GM .........................43 RENVELA TAB 800MG ........................43 repaglinide .......................................37 RESCON ..........................................68

RESCON DM .................................... 68 RESCRIPTOR ..................................... 6 RESPAIRE-30 ................................... 68 RESTASIS ....................................... 64 RETAINE MGD .................................. 64 RETROVIR IV INFUSION ...................... 6 REVATIO ......................................... 22 REVLIMID........................................ 52 REXULTI ......................................... 30 REYATAZ ........................................... 6 RHINARIS ....................................... 68 ribapak mis 600/day ........................... 8 ribasphere ......................................... 8 ribasphere ribapak 1000 ..................... 8 ribasphere ribapak 1200 ..................... 8 ribasphere ribapak 800 ....................... 8 ribavirin 200mg ................................. 8 riboflavin......................................... 61 RID ESSENTIAL LICE ELIMIN ............. 74 rifabutin ............................................ 7 rifampin ............................................ 7 RIFATER............................................ 7 riluzole ........................................... 33 rimantadine hydrochloride ................... 8 RINGER'S ........................................ 57 RISA-BID PROBIOTIC ....................... 44 RISAMINE ....................................... 73 RISPERDAL INJ 12.5MG .................... 30 RISPERDAL INJ 25MG ....................... 30 RISPERDAL INJ 37.5MG .................... 30 RISPERDAL INJ 50MG ....................... 30 risperidone ...................................... 30 RITUXAN ......................................... 13 rivastigmine tartrate ......................... 26 rivastigmine td patch 24hr 13.3 mg/24hr ...................................................... 26 rivastigmine td patch 24hr 4.6 mg/24hr ...................................................... 26 rivastigmine td patch 24hr 9.5 mg/24hr ...................................................... 26 rizatriptan benzoate ......................... 33 ROBITUSSIN CHILDRENS COUG ......... 68 ROBITUSSIN PEAK COLD NIGH .......... 68 ropinirole hydrochloride .................... 28 rosadan cre 0.75% ........................... 73 ROTARIX ......................................... 54 ROTATEQ ........................................ 54 roxicet soln ....................................... 4 95

roxicet tab 5-325mg........................... 4 ROZEREM ........................................32 RYMED ............................................68 S SABRIL ............................................25 saline ..............................................68 SANDIMMUNE ..................................53 SANDOSTATIN LAR DEPOT .................42 SANTYL ...........................................74 SAPHRIS ..........................................30 SCOOBY-DOO ONE A DAY ..................61 SCOT-TUSSIN SENIOR ......................68 SECURA EXTRA PROTECTIVE ..............73 selegiline hcl ....................................28 selenium ..........................................59 SELENIUM ........................................59 selenium sulfide ................................71 SELZENTRY ....................................... 6 SENNA ............................................47 SENNA PROMPT ................................47 sennosides .......................................47 sennosides-docusate sodium ..............47 SENSI-CARE PROTECTIVE BAR ...........73 SENSIPAR ........................................37 SEREVENT DISKUS ...........................66 SEROQUEL XR ............................ 30, 31 sertraline hcl ....................................27 setlakin tab ......................................40 sharobel 28 day ................................40 SIGNIFOR ........................................42 sildenafil citrate (pulmonary hypertension) ...................................22 SILENOR ..........................................32 SILVER SULFADIAZINE ......................71 SIMBRINZA ......................................63 simvastatin ......................................18 sirolimus ..........................................53 SIROLIMUS ......................................53 SIRTURO .......................................... 7 SIVEXTRO ......................................... 5 slow release iron ...............................51 SLOW RELEASE IRON ........................51 SLOW-MAG ......................................59 SM CORAL CALCIUM ..........................59 SM SLOW RELEASE IRON ...................51 SM VITAMIN D3 MAXIMUM STR ..........61 SODIUM BICARBONATE .....................44 SODIUM CHLORIDE ..................... 55, 57

SODIUM CHLORIDE 0.45% VIA .......... 57 SODIUM CHLORIDE 0.9%.................. 74 sodium chloride hypertonic ................ 64 SODIUM CHLORIDE INJ 0.9% ............ 57 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ............................... 55 sodium phenylbutyrate ..................... 41 sodium phosphates .......................... 47 sodium polystyrene sulfonate ............ 37 SOLTAMOX ...................................... 13 SOLU-CORTEF ................................. 42 SOMATULINE DEPOT ........................ 42 SOMAVERT ...................................... 42 SOOTHE .......................................... 64 sorine ............................................. 18 sotalol hcl ....................................... 18 sotalol hcl (afib/afl) .......................... 18 SOVALDI ........................................... 8 specialty vitamins products ............... 61 spironolactone ................................. 16 spironolactone & hydrochlorothiazide .. 21 sprintec 28 day ................................ 40 SPRITAM ......................................... 25 SPRYCEL ......................................... 14 sps susp 15gm/60ml ........................ 37 sronyx ............................................ 40 SSD................................................ 71 STAHIST AD .................................... 68 stavudine .......................................... 7 STERILE LUBRICANT DROPS .............. 64 STERILE WATER IRRIGATION ............ 74 STIVARGA ....................................... 14 STRATTERA ..................................... 32 streptomycin sulfate ........................... 4 STRIBILD .......................................... 7 SUBOXONE MIS 12-3MG ................... 35 SUBOXONE MIS 2-0.5MG .................. 34 SUBOXONE MIS 4-1MG ..................... 34 SUBOXONE MIS 8-2MG ..................... 34 SUCRAID......................................... 47 sucralfate ........................................ 47 sulfacet sod oin 10% op .................... 62 sulfacetamide sodium (acne) ............. 70 sulfacetamide sodium (ophth) ............ 62 sulfacetamide sod-prednisolone ......... 62 sulfadiazine ....................................... 4 sulfamethoxazole-trimethoprim ............ 5 sulfamethoxazole-trimethoprim inj ....... 5 96

SULFAMYLON ...................................71 sulfasalazine ....................................45 sulfasalazine ec ................................45 sulindac ............................................ 2 SUMATRIPTAN ..................................33 SUMATRIPTAN INJ 4MG/0.5ML ...........33 sumatriptan inj 6mg/0.5ml ................33 SUMATRIPTAN INJ 6MG/0.5ML ...........33 sumatriptan succinate .......................33 suprax .............................................. 9 SUPRAX ............................................ 9 SUPREP BOWEL PREP ........................47 SURMONTIL CAP 100MG ....................27 SURMONTIL CAP 25MG ......................27 SURMONTIL CAP 50MG ......................27 SUSTIVA ........................................... 7 SUTENT ...........................................14 syeda ..............................................40 SYLATRON KIT 200MCG .....................15 SYLATRON KIT 300MCG .....................15 SYLATRON KIT 600MCG .....................15 SYMBICORT .....................................70 SYMLINPEN 120 ................................36 SYMLINPEN 60 .................................35 SYNAGIS .........................................54 SYNAREL .........................................40 SYNERCID......................................... 5 SYNRIBO .........................................15 SYNTHROID .....................................43 SYPRINE ..........................................37 SYSTANE BALANCE RESTORATI ..........64 SYSTANE OVERNIGHT THERAPY..........64 T TABLOID ..........................................12 tacrolimus ........................................53 tacrolimus (topical) ...........................74 TAFINLAR ........................................14 TAGRISSO .......................................14 TAMIFLU ........................................... 8 tamoxifen citrate ..............................13 tamsulosin hcl ..................................48 TARCEVA .........................................14 TARGRETIN ......................................74 tarina fe 1/20 28 day ........................40 TASIGNA .........................................14 tazicef .............................................. 9 tazicef vial ........................................ 9 TAZORAC .........................................71

taztia .............................................. 20 TEARS AGAIN NIGHT & DAY .............. 64 TEFLARO ........................................... 9 TEGRETOL ....................................... 25 TEGRETOL-XR .................................. 25 TEKTURNA ................................. 20, 21 TEKTURNA HCT TAB 150-12.5MG ....... 21 TEKTURNA HCT TAB 150-25MG .......... 21 TEKTURNA HCT TAB 300-12.5MG ....... 21 TEKTURNA HCT TAB 300-25MG .......... 21 temazepam ..................................... 32 TENIVAC ......................................... 54 terazosin hcl .................................... 16 terbinafine hcl.................................... 6 terbinafine hcl (topical) ..................... 71 terbutaline sulfate ............................ 66 terconazole vaginal .......................... 49 testosterone cypionate ...................... 35 testosterone enanthate ..................... 35 TETANUS/DIPHTHERIA TOXOID ......... 54 tetrabenazine .................................. 33 tetrahydrozoline hcl (ophth) .............. 63 tetrahydrozoline w/ zinc sulfate ......... 63 texacort soln 2.5% ........................... 73 THALOMID ...................................... 52 theo-24........................................... 70 theophylline .................................... 70 THERA/BETA-CAROTENE ................... 61 THERA-D 4000 ................................. 61 THERANATAL CORE NUTRITION ......... 61 THERATEARS ................................... 64 thiamine hcl .................................... 61 thiamine mononitrate ....................... 61 thioridazine hcl ................................ 31 thiothixene ...................................... 31 tiagabine hcl .................................... 25 TIKOSYN ......................................... 18 timolol maleate ................................ 19 timolol maleate (ophth) .................... 63 TIMOLOL MALEATE GEL..................... 64 tioconazole vaginal ........................... 49 TIVICAY ............................................ 7 tizanidine hcl ................................... 34 TOBRADEX ...................................... 62 TOBRADEX ST ................................. 62 tobramycin ........................................ 4 tobramycin (ophth) .......................... 62 tobramycin sulfate ............................. 4 97

tobramycin-dexamethasone ...............62 TOBREX ...........................................62 tolnaftate .........................................71 tolterodine tartrate cap er ..................49 tolterodine tartrate tabs .....................49 topiramate .......................................25 toposar ............................................15 topotecan hcl ...................................15 torsemide inj ....................................21 torsemide tabs .................................21 TOUJEO SOLOSTAR ...........................36 TOVIAZ ...........................................49 TPN ELECTROLYTES ..........................55 TRACLEER ........................................22 TRADJENTA ......................................37 tramadol hcl ...................................... 2 tramadol-acetaminophen .................... 2 trandolapril ......................................16 tranexamic acid ................................51 TRANSDERM-SCOP............................45 tranylcypromine sulfate .....................27 TRAVASOL .......................................55 TRAVATAN Z ....................................64 trazodone hcl ...................................27 TREANDA .........................................11 TRECATOR ........................................ 8 TRELSTAR DEP INJ 3.75MG ................13 TRELSTAR LA INJ 11.25MG ................13 TRESIBA FLEXTOUCH ........................36 tretinoin ..........................................70 TRETINOIN ......................................70 tretinoin (chemotherapy) ...................15 triamcinolone acetonide (mouth) ........74 triamcinolone acetonide (topical) ........73 TRIAMINIC COUGH & RUNNY N...........65 TRIAMINIC FEVER REDUCER P ............. 1 TRIAMINIC NIGHT TIME COLD ............68 triamterene & hydrochlorothiazide ......21 triamterene & hydrochlorothiazide cap 37.5-25 mg ......................................21 TRIBENZOR TAB 20-5-12.5MG............17 TRIBENZOR TAB 40-10-12.5 ..............17 TRIBENZOR TAB 40-10-25MG.............17 TRIBENZOR TAB 40-5-12.5MG............17 TRIBENZOR TAB 40-5-25MG ..............17 triderm ............................................73 trifluoperazine hcl .............................31 trifluridine ........................................62

trihexyphenidyl hcl ........................... 28 tri-legest 28 day .............................. 40 trilyte ............................................. 47 trimethoprim ..................................... 5 trimipramine maleate .................. 27, 28 TRINESSA ....................................... 40 TRIPLE PASTE .................................. 74 tri-previfem 28 day .......................... 40 triprolidine & pseudoephedrine ........... 68 TRISENOX ....................................... 15 tri-sprintec 28 day ............................ 40 TRIUMEQ .......................................... 7 TRI-VI-SOL ..................................... 61 trivora 28 day .................................. 40 TROPHAMINE INJ 10% ...................... 55 trospium chloride ............................. 49 TRULICITY....................................... 36 TRUMENBA ...................................... 54 TRUVADA .......................................... 7 TUSNEL .......................................... 68 TUSNEL PEDIATRIC .......................... 68 TUSNEL-DM PEDIATRIC .................... 68 TWINRIX INJ ................................... 54 TYBOST ............................................ 7 TYGACIL ........................................... 5 TYKERB........................................... 14 TYPHIM VI ....................................... 54 TYSABRI ......................................... 33 TYZEKA............................................. 8 U UCERIS ........................................... 45 ULORIC ............................................. 1 UNITHROID ..................................... 43 UPCAL D ......................................... 59 UPTRAVI ......................................... 22 ursodiol .......................................... 47 V VAGIFEM ......................................... 41 valacyclovir hcl .................................. 8 VALCHLOR ...................................... 74 VALCYTE ........................................... 8 valganciclovir hcl ................................ 8 valproate sodium ............................. 25 valproic acid .................................... 25 valsartan ......................................... 17 valsartan & hctz tab 160-12.5mg ....... 17 valsartan & hctz tab 160-25mg .......... 17 valsartan & hctz tab 320-12.5mg ....... 17 98

valsartan & hctz tab 320-25mg...........17 valsartan & hctz tab 80-12.5mg..........17 vancomycin hcl .................................. 5 VANDAZOLE .....................................49 VAQTA.............................................54 VARIVAX ..........................................54 VASCEPA .........................................19 VELCADE .........................................13 velivet 28 day ..................................40 venlafaxine hcl .................................28 VENTOLIN HFA .................................66 verapamil cap er ...............................20 VERAPAMIL CAP ER ...........................20 verapamil hcl ...................................20 verapamil tab er ...............................20 VERSACLOZ .....................................31 VESICARE ........................................49 vestura ............................................40 VICKS VAPORUB ...............................68 VICTOZA .........................................36 VIDEX PEDIATRIC .............................. 7 vienva 28 day...................................40 VIGAMOX .........................................62 VIIBRYD ..........................................28 VIIBRYD STARTER PACK ....................28 VIMPAT ...........................................25 vinblastine sulfate .............................12 vincasar ...........................................12 vincristine sulfate ..............................12 vinorelbine tartrate ...........................12 viorele .............................................40 VIRACEPT ......................................... 7 VIRAMUNE XR ................................... 7 VIREAD ............................................ 7 VISINE-LR .......................................63 VITALETS .........................................61 VITAMIN A PALMITATE ......................61 VITAMIN B12/FOLIC ACID ..................51 vitamin c .........................................61 VITAMIN C .......................................61 VITAMIN D2 .....................................61 VITAMIN D3 .....................................61 vitamin e .........................................61 VITAMIN E .......................................61 vitamin mixture ................................61 vitamins a & d ..................................61 VITEKTA ........................................... 7 VOLTAREN .......................................74

voriconazole ...................................... 6 VOTRIENT ....................................... 14 VRAYLAR ......................................... 31 vyfemla 28 day ................................ 40 W warfarin sodium ............................... 50 WELCHOL ........................................ 19 wheat dextrin-calcium ...................... 47 white petrolatum-mineral oil .............. 64 X XALKORI ......................................... 14 XARELTO......................................... 50 XARELTO STARTER PACK .................. 50 XGEVA ............................................ 42 XIFAXAN ......................................... 47 XIGDUO XR TAB 10-1000MG ............. 37 XIGDUO XR TAB 10-500MG ............... 37 XIGDUO XR TAB 5-1000MG ............... 37 XIGDUO XR TAB 5-500MG ................. 37 XOLAIR ........................................... 69 XOPENEX HFA .................................. 66 XTANDI ........................................... 13 xulane ............................................ 40 XYREM ............................................ 34 Y YERVOY .......................................... 13 YF-VAX ........................................... 54 Z zafirlukast ....................................... 69 zarah .............................................. 40 ZAVESCA ........................................ 41 zazole ............................................. 49 ZAZOLE .......................................... 49 ZELBORAF ....................................... 14 ZEMAIRA ......................................... 69 zenatane ......................................... 70 zenchent 28 day .............................. 40 ZENPEP ........................................... 47 ZETIA TAB 10MG.............................. 19 ZIAGEN............................................. 7 zidovudine ......................................... 7 ZINC OXIDE .................................... 74 zinc oxide (topical) ...................... 71, 74 ziprasidone hcl ................................. 31 ZIRGAN .......................................... 62 zoledronic acid ................................. 37 zoledronic inj 4mg/5ml ..................... 37 ZOLINZA ......................................... 13 99

zolmitriptan......................................33 zolmitriptan odt ................................33 zolpidem tartrate ..............................32 zonatuss ..........................................68 zonisamide.......................................25 ZONTIVITY .......................................51 ZOO FRIENDS COMPLETE ..................61 ZORTRESS TAB 0.25MG .....................53 ZORTRESS TAB 0.5MG ......................53 ZORTRESS TAB 0.75MG .....................53

ZOSTAVAX ...................................... 54 zovia 1/35e 28 day........................... 40 zovia 1/50e 28 day........................... 40 ZYDELIG ......................................... 14 ZYKADIA ......................................... 14 ZYLET ............................................. 62 ZYPREXA RELPREVV ......................... 31 ZYPREXA RELPREVV INJ 210MG ......... 31 ZYTIGA ........................................... 13 ZYVOX .............................................. 5

100

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